HomeMy WebLinkAboutAgreement A-23-059 Amendment I to Master Agreement.pdf Agreement No. 23-059
1 AMENDMENT I TO AGREEMENT
2 THIS AMENDMENT, hereinafter referred to as Amendment I, is made and entered into this
3 7th day of February , 2023 by and between the COUNTY OF FRESNO, a Political Subdivision of
4 the State of California, hereinafter referred to as "COUNTY", and each CONTRACTOR listed in Exhibit
5 A "List of Contractors" attached hereto and incorporated herein by reference, and collectively
6 hereinafter referred to as "CONTRACTOR(S)", and such additional CONTRACTOR(S) as may, from
7 time to time during the term of this Agreement, be added or deleted by COUNTY. Reference in this
8 Agreement to party or "parties" shall be understood to refer to COUNTY and each individual
9 CONTRACTOR(S), unless otherwise specified.
10 WITNESSETH
11 WHEREAS, the parties entered into that certain Agreement, identified as COUNTY Agreement
12 No. A-21-258, effective July 1, 2021, whereby, CONTRACTORS agreed to provide geropsychiatric
13 skilled nursing care, locked skilled nursing care with special mental health treatment programs, mental
14 health rehabilitation center services, ancillary services and other enhanced treatment services and
15 other facilities to house and treat adults with severe and serious mental health impairments; and
16 WHEREAS, each CONTRACTOR has the secured facilities, staff and expertise, and is licensed
17 by the State of California, to provide residential mental health services, and ancillary services to
18 severely and persistently mentally disabled persons in appropriate skilled nursing or mental health
19 rehabilitation center facilities; and
20 WHEREAS, CONTRACTOR 7th Avenue Center was included in COUNTY Agreement No. A-21-
21 258 when it was executed effective July 1, 2021 with no changes to its Exhibit C-1, "DESCRIPTION OF
22 SERVICES & RATES"; and
23 WHEREAS, CONTRACTOR CF Merced Behavioral, LLC, d.b.a. Merced Behavioral Center was
24 included in COUNTY Agreement No. A-21-258 when it was executed effective July 1, 2021, and it has
25 updated its "DESCRIPTION OF SERVICES & RATES" pursuant to the DBH Director's authority in
26 Section 14 of COUNTY Agreement No. A-21-258. The updated "DESCRIPTION OF SERVICES &
27 RATES" and signature page is attached to this Amendment as Revised Exhibit C-2, effective July 1,
28 2022; and
-1 - COUNTY OF FRESNO
Fresno, CA
1 WHEREAS, CONTRACTOR Crestwood Behavioral Health Inc. was included in COUNTY
2 Agreement No. A-21-258 when it was executed effective July 1, 2021, and it has updated its
3 "DESCRIPTION OF SERVICES & RATES" pursuant to the DBH Director's authority in Section 14 of
4 COUNTY Agreement No. A-21-258. The updated "DESCRIPTION OF SERVICES & RATES" and
5 signature page is attached to this Amendment as Revised Exhibit C-3, effective July 1, 2022; and
6 WHEREAS, CONTRACTOR Vista Pacifica Enterprises, Inc. d.b.a. Vista Pacifica Center and
7 d.b.a. Vista Pacifica Convalescent was included in COUNTY Agreement No. A-21-258 when it was
8 executed effective July 1, 2021, and it has updated its "DESCRIPTION OF SERVICES & RATES"
9 pursuant to the DBH Director's authority in Section 14 of COUNTY Agreement No. A-21-258. The
10 updated "DESCRIPTION OF SERVICES & RATES" and signature pages are attached to this
11 Amendment as Revised Exhibit C-4a and Revised Exhibit C-4b, effective July 1, 2022; and
12 WHEREAS, CONTRACTOR Helios Healthcare, LLC., d.b.a. Idylwood Care Center was
13 included in COUNTY Agreement No. A-21-258 when it was executed effective July 1, 2021, and it has
14 updated its "DESCRIPTION OF SERVICES & RATES" pursuant to the DBH Director's authority in
15 Section 14 of COUNTY Agreement No. A-21-258. The updated "DESCRIPTION OF SERVICES &
16 RATES" and signature page is attached to this Amendment as Revised Exhibit C-5, effective July 1,
17 2022; and
18 WHEREAS, CONTRACTOR KF Community Care, LLC, d.b.a. Community Care Center was
19 included in COUNTY Agreement No. A-21-258 when it was executed effective July 1, 2021, and it has
20 updated its "DESCRIPTION OF SERVICES & RATES" pursuant to the DBH Director's authority in
21 Section 14 of COUNTY Agreement No. A-21-258. The updated "DESCRIPTION OF SERVICES &
22 RATES" and signature page is attached to this Amendment as Revised Exhibit C-6, effective July 1,
23 2022; and
24 WHEREAS, the DBH Director previously added CONTRACTOR Telecare Corporation to
25 COUNTY Agreement No. A-21-258 through her authority to add CONTRACTORS pursuant to Section
26 14 of COUNTY Agreement No. A-21-258, with an effective date of July 1, 2022. Its current
27 "DESCRIPTION OF SERVICES & RATES" and signature pages are attached to this Amendment as
28
-2- COUNTY OF FRESNO
Fresno, CA
1 Revised Exhibit C-7a, Revised Exhibit C-7b, Revised Exhibit C-7c, Revised Exhibit C-7d, Revised
2 Exhibit C-7e, Revised Exhibit C-7f, and Revised Exhibit C-7g; and
3 WHEREAS, the DBH Director previously added CONTRACTOR Mental Health Management I,
4 Inc., d.b.a. Canyon Manor to COUNTY Agreement No. A-21-258 through her authority to add
5 CONTRACTORS pursuant to Section 14 of COUNTY Agreement No. A-21-258, with an effective date
6 of July 1, 2022. Its current "DESCRIPTION OF SERVICES & RATES" and signature page is attached
7 to this Amendment as Exhibit C-8; and
8 WHEREAS, the DBH Director previously added CONTRACTOR Medical Hill Rehab Center,
9 LLC, d.b.a. Kindred Nursing and Rehabilitation — Medical Hill to COUNTY Agreement No. A-21-258
10 through her authority to add CONTRACTORS pursuant to Section 14 of COUNTY Agreement No. A-
11 21-258, with an effective date of July 1, 2022. Its current "DESCRIPTION OF SERVICES & RATES"
12 and signature page is attached to this Amendment as Revised Exhibit C-9; and
13 WHEREAS, the DBH Director previously added CONTRACTOR Community Care of Palm
14 Riverside, LLC to COUNTY Agreement No. A-21-258 through her authority to add CONTRACTORS
15 pursuant to Section 14 of COUNTY Agreement No. A-21-258, with an effective date of April 6, 2022. Its
16 current "DESCRIPTION OF SERVICES & RATES' and signature page is attached to this Amendment
17 as Exhibit C-10; and
18 WHEREAS, the DBH Director previously added CONTRACTOR California Psychiatric
19 Transitions to COUNTY Agreement No. A-21-258 through her authority to add CONTRACTORS
20 pursuant to Section 14 of COUNTY Agreement No. A-21-258, with an effective date of July 1, 2022. Its
21 current "DESCRIPTION OF SERVICES & RATES' and signature page is attached to this Amendment
22 as Revised Exhibit C-11; and
23 WHEREAS, the DBH Director previously added CONTRACTOR Golden State Health Centers,
24 Inc., d.b.a. Sylmar Health and Rehabilitation Center to COUNTY Agreement No. A-21-258 through her
25 authority to add CONTRACTORS pursuant to Section 14 of COUNTY Agreement No. A-21-258, with
26 an effective date of July 1, 2022. Its current "DESCRIPTION OF SERVICES & RATES' and signature
27 page is attached to this Amendment as Revised Exhibit C-12; and
28
-3- COUNTY OF FRESNO
Fresno, CA
1 WHEREAS, the COUNTY now desires to add CONTRACTOR Countryside Care Center, LLC to
2 COUNTY Agreement No. A-21-258. Its "DESCRIPTION OF SERVICES & RATES" and signature page
3 is attached to this Amendment as Exhibit C-13; and
4 WHEREAS, the parties desire to amend COUNTY Agreement 21-258 to memorialize these
5 changes as stated below.
6 NOW, THEREFORE, for good and valuable consideration, the receipt and adequacy of which is
7 hereby acknowledged, the parties agree as follows:
8 1. All references to Exhibit A shall be deemed references to Revised Exhibit A, which is
9 attached and incorporated by this reference.
10 2. All references to Exhibit C shall be deemed references to CONTRACTORS'
11 corresponding Exhibit C sub-part, "DESCRIPTION OF SERVICES & RATES," as indicated on Revised
12 Exhibit A. Each corresponding Exhibit C sub-part is attached and incorporated by this reference.
13 3. CONTRACTORS hereby agree to all terms of the Agreement, as amended, and agree to
14 be bound by the terms of the Agreement, as amended. CONTRACTORS hereby acknowledge that they
15 have received a complete copy of the Agreement, as amended.
16 4. The parties agree that upon execution of this Amendment, COUNTY Agreement No.
17 A-21-258 is further revised, updated and amended to add CONTRACTOR Countryside Care Center,
18 LLC.
19 5. Each CONTRACTOR'S corresponding Exhibit C sub-part described above shall include
20 the signature pages executed by the CONTRACTORS. The Revised Exhibits will be included with and
21 attached to COUNTY Agreement No. A-21-258 after execution by the CONTRACTORS. Pursuant to
22 Section 14 of COUNTY Agreement No. A-21-258, this Amendment is hereby executed by the COUNTY
23 without notice to or approval of any of the other CONTRACTORS to COUNTY Agreement No. A-21-
24 258, as amended.
25 6. The parties agree that this Amendment I is sufficient to amend the Agreement; and that
26 upon execution of this Amendment I, the Agreement and Amendment I together shall be considered the
27 Agreement.
28
-4- COUNTY OF FRESNO
Fresno, CA
1 The Agreement, as hereby amended, is ratified and continued. All provisions, terms,
2 covenants, conditions and promises contained in the Agreement and not amended herein shall remain
3 in full force and in effect. This Amendment I shall be effective upon execution.
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-5- COUNTY OF FRESNO
Fresno, CA
1 IN WITNESS WHEREOF, the parties hereto have executed this Amendment I to Agreement No.
2 A-21-258 as of the day and year first hereinabove written.
3
4 CONTRACTOR(S): COUNTY OF FRESNO
5 PLEASE SEE SIGNATURE
PAGES ATTACHED
6
7 "al Q i er , Chairman of the Board of
Sup i f the County of Fresno
8
9 ATTEST:
10 Bernice E. Seidel
Clerk of the Board of Supervisors
11 County of Fresno, State of California
12
By: AZZ
13 Deputy
14
15
16
17
18 FOR ACCOUNTING USE ONLY:
Fund/Subclass: 0001/10000
19 Organization: 56302175
Account/Program: 7295/0
20
21 $133,577,211 Term Maximum
22 $21,879,610 FY 2021-22
$24,067,571 FY 2022-23
23 $26,474,329 FY 2023-24
$29,121,762 FY 2024-25
24 $32,033,939 FY 2025-26
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6 COUNTY OF FRESNO
Fresno,CA
1 CONTRACTOR: COUNTRYSIDE CARE CENTER, LLC
2
By "fj , � I,,— -
3
4 Print Name: Jacob Unger
5
6 Title: President
Chairman of the Board, President, or Vice President
7
8 Date: January 11, 2023
9
10
11 By
12
Print Name: Jacob Unger
13
14 Title: Chief Financial Officer
15 Secretary (of Corporation), Assistant Secretary,
Chief Financial Officer, or Assistant Treasurer
16
17 Date: January 11, 2023
18
19 MAILING ADDRESS:
20
5404 Whitsett Ave STE 182
21 Valley Village, CA 91607
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-7- COUNTY OFFRESNO
Fresno,CA
Revised Exhibit A
LIST OF CONTRACTORS
CONTRACTOR NAME EXHIBIT
REFERENCE
1. 71h Avenue Center Exhibit C-1
2. CF Merced Behavioral, LLC., d.b.a. Merced Behavioral Revised Exhibit C-2
Center
3. Crestwood Behavioral Health Inc. Revised Exhibit C-3
4. Vista Pacifica Enterprises, Inc., d.b.a. Vista Pacifica Center Revised Exhibit C-4 (a-
and d.b.a. Vista Pacifica Convalescent b)
5. Helios Healthcare, LLC., d.b.a. Idylwood Care Center Revised Exhibit C-5
6. KF Community Care, LLC., d.b.a. Community Care Center Revised Exhibit C-6
7. Telecare Corporation Revised Exhibit C-7 (a-
g)
8. Mental Health Management I, Inc., d.b.a. Canyon Manor Exhibit C-8
9. Medical Hill Rehab Center, LLC., d.b.a. Revised Exhibit C-9
Kindred Nursing and Rehabilitation — Medical Hill
10. Community Care on Palm Riverside, LLC Exhibit C-10
11. California Psychiatric Transitions Revised Exhibit C-11
12. Golden State Health Centers, Inc., d.b.a. Revised Exhibit C-12
Sylmar Health and Rehabilitation Center
13. Countryside Care Center, LLC Exhibit C-13
Revised 12.16.22
EXHIBIT C-1
Page 1 of 3
DESCRIPTION OF SERVICES & RATES (FY 2021-22)
7t" AVENUE CENTER, LLC
Contractor agrees to provide County with Mental Health Rehabilitation Center (MHRC) services for
adults with mental health conditions 18 to 64, pursuant to California's Welfare and Institutions Code,
section 5900 et seq., Title 22 of the California Code of Regulations, the California Department of Health
Care Services' Policies and Directives, Title 9, California Code of Regulations, Division 1, Sub-Chapter
3.5, and other applicable statutes and regulations. Participation in MHRCs is limited to facilities that
meet the licensing and certification requirements of the California Department of Health Services
Licensing and Certification Division.
For the purposes of this Agreement, the term "bed day" includes beds held vacant for clients who are
temporarily (not more than seven (7) days) absent from a facility. A bed-hold day cannot be in place
when the client is in a psychiatric health facility (PHF) or any acute hospital for psychiatric reasons. A
bed hold can only be placed for non-psychiatric reasons, e.g., medical hospitalization.
In addition to the services listed in "Scope of Work" (Exhibit B), Contractor shall provide the following:
I. BASIC DAILY RATE SERVICES
Basic Daily Rate services consist of usual and customary MHRC services to adults with mental
health conditions. Basic Daily Rate services include reasonable access to required medical
treatment, up-to-date psychopharmacology, transportation to needed off-site services and
bilingual/bicultural programming.
II. ENHANCED SERVICES
Enhanced Services consist of specialized program services which augment basic services.
Enhanced Services are designed to serve clients who have sub-acute psychiatric impairment
and/or whose adaptive functioning is severely impaired.
The Enhanced Services bed rate or any other charges in addition to the Enhanced Services bed
rate may be negotiated for an individual client on an as-needed basis between the County's
Department of Behavioral Health (DBH) Director, or designee, and Contractor. The County's
DBH Director, or designee, must approve these rates before the client is provided any services
more intensive than the Basic Services. Approval for such services may be sought using the
Special Services Authorization Form (Exhibit G).
The need for continuing Enhanced Services will be re-assessed on a weekly to monthly basis
throughout the individual's stay.
III. REQUIREMENTS
Contractor shall provide available beds needed for authorized County clients during the term of
the Agreement. The County does not guarantee any minimum number of beds.
EXHIBIT C-1
Page 2of3
IV. RATES*
Program Services Rate
Basic Daily Rate $ per client per day
Bed Hold Rate $ per bed per day
Enhanced Services Rate O(L" 'kC"O $ to $ per bed per day
1:1 Supervision '4C,(), $ per day
Other Services Rate
Physician/Psychiatric Services" $ per visit
* All rates other than the Basic Daily Rate services must be pre-approved by the County's
DBH Director, or designee, prior to placement or initiation of such services. For any rate
higher than the Basic Rate Services, both the rationale and the extra services must be
specified and time-limited and approval must be sought using the Special Services
Authorization Form (Exhibit G).
^ Psychiatric services (provided to clients placed by County at Contractor's facilities who are
not covered by Medi-Cal, private insurance or personal/other funds) shall be billed through
the Contractor via the monthly services invoice. Psychiatric services billed by the service
provider on Health Insurance Claim Forms (HICF 1500) or other forms directly to County will
be rerouted to Contractor for inclusion in the monthly invoice. Contractor shall attach
supporting documentation verifying services provided on all psychiatric invoices submitted.
Supporting documentation should include, but are not limited to, date and location of
service, service provided, service duration, name of provider.
Should a client require 1:1 Supervision longer than 24 hours while awaiting return to his/her
home county, there will be an additional charge of,.$20O:OTper day for a period not to
exceed five (5) days. r_
Ancillary outpatient services (laboratory, x-rays, or other medical services performed offsite
to a client residing in an IMD/SNF/MHRC) must be billed directly to Medi-Cal, pursuant to
Title 22 of the CCR. County shall be informed and/or approve of any such service(s) to
Medi-Cal ineligible clients in advance of services being provided, where possible. Ancillary
charges for non-Medi-Cal clients or non-Medi-Cal billable services may be billed separately
from the monthly service invoice and submitted with supporting documentation to County.
EXHIBIT C-1
Page 3 of 3
CONTRACTOR:
Tm AVENUE CENTER, LLC
By
Print Name:
Title:
Chairman of the Board, or
President, or any Vice President or
Director ofOperations
~_-
Print Nam
{ �
Title:
Secretary (of Corpor0on), or
any Assistant Secretary, or
Chief Financial Offioer, or
any Assistant Treasurer/Facility
Administrator
Mailing Address:
Santa Cruz, CAS5O02
Phone: (831)42O-012O. Ext. 109
Email: N[}otti|e8Dhnntst.00nn
Contact: Natalie OY\tti|a. Accounting Manager
Fund: 0001/10000
Organization: 50302175
REVISED EXHIBIT C-2
Page 1 of 3
DESCRIPTION OF SERVICES & RATES (FY 2022-23)
CF MERCED BEHAVIORAL, LLC, d.b.a. MERCED BEHAVIORAL CENTER
Contractor agrees to provide County with Skilled Nursing Facility/Institutions for Mental Disease
(SNF/IMD) services to adult persons served between the ages of 18 to 64 years with mental health
conditions, pursuant to California's Welfare and Institutions Code, section 5900 et seq., Title 22 of the
California Code of Regulations, the State Department of Health Care Services' Policies and Directives;
and other applicable statutes and regulations that apply to the SNF/IMD facilities and programs.
For the purposes of this Agreement, the term "bed day" includes beds held vacant for persons served
who are temporarily [not more than seven (7) days] absent from a facility. An emergency IMD/SNF
bed-hold for psychiatric and non-psychiatric reasons beyond seven (7) day must be approved by the
County's Department of Behavioral Health (DBH) Director, or designee. The County will pay up to the
first seven (7) bed-hold days and approval must be provided by the County for any additional days after
consulting with the Contractor. The County will have the final say on a case—by-case basis if an
extended bed-hold of beyond seven (7) days is necessary. The Contractor will notify the County
immediately if Contractor has knowledge that the person served will require treatment at a facility or is
eloped lasting seven (7) days or more. A bed hold for non-psychiatric reasons include, but are not
limited to, medical hospitalization or elopement.
In addition to the services listed in "Scope of Work" (Exhibit B), Contractor shall provide the following:
I. BASIC DAILY RATE SERVICES:
Basic Daily Rate services consist of usual and customary SNF/IMD services to adult persons
served with mental health conditions, plus those services that are included in Special Treatment
programs as contained in Title 22 of the California Code of Regulations, sections 72443-72475.
Basic Daily Rate services include reasonable access to required medical treatment, up-to-date
psychopharmacology, transportation to needed off-site services and bilingual/bicultural
programming.
SPECIAL TREATMENT PROGRAMS:
Special Treatment Programs (STP) serve persons who have a chronic psychiatric impairment
and whose adaptive functioning is moderately impaired. These persons served require
continuous supervision and may be expected to benefit from an active rehabilitation program
designed to improve their adaptive functioning or prevent any further deterioration of their
adaptive functioning. Services are provided to persons having special needs or deficits in one
(1) or more of the following areas: self-help skills; behavioral adjustment; interpersonal
relationships; pre-vocation preparation, alternative placement planning, and/or pre-release
planning.
II. ENHANCED SERVICES:
Enhanced Services consist of specialized program services, which augment basic services.
Enhanced Services are designed to serve persons who have sub-acute psychiatric impairment
and/or whose adaptive functioning is severely impaired.
REVISED EXHIBIT C-2
Page 2 of 3
A charge in addition to the Enhanced Services bed rate may be negotiated for an individual
person served on an as-needed basis between the County's Department of Behavioral Health
(DBH) Director, or designee, and Contractor for Enhanced and STP services by using the
Special Services Authorization Form (Exhibit G). The County's DBH Director, or designee, must
approve these rates before the person served is placed or initiation of any enhanced services
takes place.
III. REQUIREMENTS:
Contractor shall provide up to thirty-five (35) beds per day for authorized County persons served
during each term of the Agreement. In addition, Contractor shall provide additional beds as
needed by the County, subject to availability of said beds by the Contractor. The County does
not guarantee any minimum number of beds for all services provided by the Contractor and
payment will be based on usage.
IV. RATES:
Program Services 1 Rate
Basic Daily Rate _ _ $218.47
Bed Hold Rate* $209.57 '
Enhanced Services Rate** Negotiable with Pre-Authorization
* Bed Hold Rate — Person Served out at Hospital. Above rate will be paid up to seven (7) days
without authorization required.
**All rates other than the Basic Daily Rate services must be pre-approved by the County's DBH
Director, or designee, prior to placement or initiation of such services. For any rate higher than
the Basic Rate Services, both the rationale and the extra services must be specified and time-
limited and approval must be sought using the Special Services Authorization Form (Exhibit G).
Rates are inclusive of psychiatric services.
Rate is set at the State Medi-Cal rate and will be adjusted if the Medi-Cal rate changes. In the
event a person served is placed who does not have Medi-Cal and is under age 65, County will
pay both the "with Medi-Cal" rate and the "without Medi-Cal" rate above to cover room and
board charges.
Ancillary outpatient services (laboratory, x-rays, or other medical services performed offsite to a
person served residing in an IMD/SNF/MHRC) must be billed directly to Medi-Cal, pursuant to
Title 22 of the CCR. County shall be informed and/or approve of any such service(s) to Medi-
Cal ineligible persons served in advance of services being provided, where possible. Ancillary
charges for non-Medi-Cal persons served or non-Medi-Cal billable services may be billed
separately from the monthly service invoice and submitted with supporting documentation to
County.
REVISED EXHIBIT C-2
Page 3 of 3
REVIEWED AND RECOMMENDED FOR APPROVAL:
By
Susan L Holt, Director
Department of Behavioral Health
CONTRACTOR:
CIF MERCED BEHAVIORAL CENTER, LLC,
d.b.a. MERCED BEHAVIORAL CENTER
By
Print Name: Ere /3a ��►
Title: D:r ocicn Q
Chairman of the Board, or
President, or any Vice President or
Director of Operations
By
Print Name:
Title: _ r��{�YJ�fI ���•1��/ —
Secretary (of Corporation), or
any Assistant Secretary, or
Chief Financial Officer, or
any Assistant Treasurer/Facility
Administrator
Mailing Address:
1255 "B" Street
Merced, CA 95341
Phone: (209) 723-8814
Fax: (209) 384-3747
Email: Jeri.Allgood@mercedbehavioralhcc.com
Contact: Jeri Allgood, Administrator
Fund: 0001/10000
Organization: 56302175
Account/Program: 7295/0
REVISED EXHIBIT C-3
Agt. 21-258
DESCRIPTION OF SERVICES & RATES (FY 2022-23)
CRESTWOOD BEHAVORIAL HEALTH, INC.
Contractor has many facilities throughout the State of California providing all services listed in Exhibit B
and agrees to provide County with the agreed upon services for adult persons served with mental
health conditions, pursuant to Welfare and Institutions Code, Section 5900 et seq., Title 22 of the
California Code of Regulations, the California Department of Health Care Services' Policies and
Directives, and other applicable statues and regulations at the following types of facilities: Skilled
Nursing Facility (SNF), Institutions of Mental Disease (IMD), Geropsychiatric Nursing Care Facilities
(GNCF), and Mental Health Rehabilitation Center (MHRC).
For the purposes of this Agreement, the term "bed day" includes beds held vacant for persons served
who are temporarily [not more than seven (7) days] absent from a facility. An emergency bed-hold for
psychiatric and non-psychiatric must be approved by the County's Department of Behavioral Health
(DBH) Director, or designee. The County will pay up to the first seven (7) bed-hold days and approval
must be provided by the County by using the Special Services Authorization Form (Exhibit G). The
County will have the final say on a case—by-case basis if an extended bed-hold of beyond seven (7)
days is necessary. The Contractor will notify the County immediately if Contractor has knowledge that
the person served will require treatment at a facility or is eloped lasting seven (7) days or more. A bed
hold for non-psychiatric include, but are not limited to, medical hospitalization or elopement.
In addition to the services listed in "Scope of Work" (Exhibit B), Contractor shall provide the following:
I. BASIC DAILY RATE SERVICES:
Basic Daily Rate services are listed by facility listed in Exhibit C-3 pages 3 through 5. Services
provided are itemized within the "Scope of Work" (Exhibit B).
SPECIAL TREATMENT PROGRAMS:
Special Treatment Programs (STP) serve persons who have a chronic psychiatric impairment
and whose adaptive functioning is moderately impaired. These persons served require
continuous supervision and may be expected to benefit from an active rehabilitation program
designed to improve their adaptive functioning or prevent any further deterioration of their
adaptive functioning. Services are provided to persons served having special needs or deficits
in one (1) or more of the following areas: self-help skills; behavioral adjustment; interpersonal
relationships; pre-vocation preparation, alternative placement planning, and pre-release
planning.
II. ENHANCED SERVICES:
Enhanced Services consist of specialized program services, which augment basic services.
Enhanced Services are designed to serve persons who have sub-acute psychiatric impairment
and/or whose adaptive functioning is severely impaired. A charge in addition to the Enhanced
Services bed rate may be negotiated for a person served on an as-needed basis between the
County's Department of Behavioral Health (DBH) Director, or designee, and Contractor for
Enhanced and STP services by using the Special Services Authorization Form (Exhibit G). The
County's DBH Director, or designee, must approve these rates before the person served is
placed or initiation of any enhanced services takes place.
Page 1 of 6
REVISED EXHIBIT C-3
Agt. 21-258
III. REQUIREMENTS:
Contractor shall provide available beds needed for authorized County persons served during
each term of this Agreement. The County does not guarantee any minimum number of
beds for all services provided by the Contractor and payment will be based on usage.
IV. RATES:
Contractor's rates are identified in pages 3 - 5 of this Exhibit C-3.
All rates other than the Basic Daily Rate services must be pre-approved by the County's DBH
Director, or designee, prior to placement or initiation of such services. For any rate higher
than the Basic Rate Services, both the rationale and the extra services must be specified and
time-limited and approval must be sought using the Special Services Authorization Form
(Exhibit G). Ancillary outpatient services (laboratory, x-rays, or other medical services
performed offsite to a person served residing in an IMD/SNF/MHRC) must be billed directly to
Medi-Cal, pursuant to Title 22 of the CCR. County shall be informed and/or approve of any
such service(s) to Medi-Cal ineligible persons served in advance of services being provided,
where possible. Ancillary charges for non-Medi-Cal persons served or non-Medi-Cal billable
services may be billed separately from the monthly service invoice and submitted with
supporting documentation to County.
Page 2 of 6
CRESTWOOD BEHAVIORAL HEALTH, INC. 71112022
**The rate reduction for bed hold or leave of absence for acute hospitalization is $8.93 (raw
food cost) per diem for dates of service for FY 22-23.
SNF/STP-IMD Designation Room and Board/Per Diem Patch/Enhancement
Crestwood Wellness and 243.40 27.00
Recovery Ctr 49.00
Redding IMD—1122 65.00
NPI - 1194743088 125.00
Negotiated
SNF STP Room and Board/Per Diem Patch/Enhancement
Crestwood Manor Medi-Cal Published Rate 27.00
Stockton SNF/STP—1104 *Indigent/Medi-Cal Ineligible 39.00
NPI - 1730128174 41.00
65.00
94.00
125.00
Negotiated
Crestwood Manor Medi-Cal Published Rate 27.00
Modesto SNF- 1112 *Indigent/Medi-Cal Ineligible 44.00
NPI- 1508884487 65.00
94.00
125.00
Negotiated
Crestwood Manor-Fremont Medi-Cal Published Rate 27.00
Alameda SNF/STP- 1134 *Indigent/Medi-Cal Ineligible 35.00
NPI - 1902828403 65.00
103.00
150.00
Negotiated
SNF Room and Board/Per Diem Patch/Enhancement
Crestwood Treatment Center Medi-Cal Published Rate 150.00
Fremont SNF- 1120 *Indigent/Medi-Cal Ineligible Negotiated
NPI - 1942228838
Page 3 of 6
Current Rate minus Raw Food Cost**
CRESTWOOD BEHAVIORAL HEALTH, INC. 71112022
The following rates include room and board, nursing care, special treatment program services,
activity programs, OTC medications, dietary, etc. Physician services, pharmacy and other ancillary
medical services are not included in the per diem rate and are separately billable in accordance with
Title 9.
Mental Health Rehabilitation Centers
Crestwood Center Level 1 389.00
Sacramento MHRC- 1106 Level 2 354.00
NPI - 1356411656 Level 3 321.00
Bed Hold **
Crestwood Behavioral Health Ctr Level 1 424.00
San Jose MHRC- 1107 Level 2 340.00
NPI - 1376623256 Level 3 331.00
Bed Hold **
Crestwood Behavioral Health Ctr 334.00
Eureka MHRC- 1110 Bed Hold **
NPI - 1124046008
Crestwood Behavioral Health Ctr Level (1:1) 720.00
Bakersfield MHRC- 1115 MIST 450.00
NPI - 1275610800 Level 1 389.00
Level 2 354.00
Level 3 319.00
Bed Hold **
Crestwood C.E.N.T.E.R. Level 1 380.00
Angwin MHRC- 1116 Level 2 302.00
NPI - 1316024953 Level 3 249.00
Bed Hold **
Kingsburg Healing Center Level 1 494.00
Kingsburg MHRC- 1140 Level 2 437.00
NPI—1073989661 Level 3 375.00
Bed Hold **
Crestwood Recovery and Rehab Level 1 391.00
Vallejo MHRC- 1141 Level 2 332.00
NPI - 1508935834 Level 3 294.00
Level 4 276.00
Bed Hold **
Page 4 of 6
Current Rate minus Raw Food Cost"
CRESTWOOD BEHAVIORAL HEALTH, INC. 71112022
Crestwood San Diego Level 1 469.00
San Diego MHRC- 1154 Level 2 402.00
NPI - 1295146934 Level 3 334.00
Bed Hold **
Crestwood Chula Vista Level 1 469.00
Chula Vista MHRC- 1164 Level 2 402.00
NPI- 1023495181 Level 3 334.00
Bed Hold **
San Francisco Healing Center 519.00
San Francisco MHRC- 1166 Bed Hold **
NPI - 1447758024
Fallbrook Healing Center Level 1 487.00
Fallbrook Healing- 1167 Level 2 417.00
NPI - 1639738297 Level 3 348.00
Bed Hold **
Champion Healing Center MIST 550.00
Lompoc- 1170 Level 1 541.00
NPI -31487282273 Level 2 458.00
Level 3 380.00
Bed Hold **
Page 5 of 6
Current Rate minus Raw Food Cost**
REVISED EXHIBIT C-3
Agt.21-258
REVIEWED AND RECOMMENDED FOR APPROVAL:
By
Susan L It, Director
Department of Behavioral Health
CONTRACTOR:
CRESTWOOD BEHAVORIAL HEALTH, INC.
By
Print Name: Chen A 19'�QSA �V
Title: Cx e c 21 f/ Ve
Chairman of the Board, or President, C ah
or any Vice President or Director of
Operations
Mailing Address:
520 Capitol Mall, Suite 800
Sacramento, CA 95814
Phone: (916) 764-5310
Fax: (916) 471-2212
Email: elena.mashkevich@cbhi.net
Contact: Elena Mashkevich
Fund: 0001/10000
Organization: 56302175
Account/Program: 7295/0
Page 6 of 6
E)(HiBITC-4a
Page of
DESCRIPTION OF SERVICES P. RATES (FY2822-23)
VISTA PAC|F}C/\ ENTERPRISES, |NC,
d.b.a. y|STA PACiF}C/\ CENTER
Contractor agrees to provide County with Skilled Nursing Facility (SNF)8nsdtuti0ns for Mental Disease
(|K8O) services for mentally disabled adult persons ages 18 or o|der, pursuant to California's Welfare
and Institutions Code. Division 5, commencing with section GOOU' Tide 22 of the California Code of
Regulations, sections 72801, etaoq., the California Department ofHealth Can* Services' Policies and
Din*ctives, and other applicable statutes and regulations.
For the purposes of this Agreement, the term "bed day" includes beds held vacant for persons served
who are temporarily [not more than seven (7) days] absent from afaci|ky. An emergency |K4D/SNF
bed-hold for psychiatric and non--psychiatric reasons beyond seven (7) day Must beapproved by the
Counh/'s Department ofBehavioral Health (DBH) Director. or designee, The County will pay LIP to the
first seven (7) bed-hold days and approval must be provided by the County for any additional days after
oonsu|ting with the ConLraoLnr. The County will have the final say on o case—by-oase basis if an
extended bed-hold of beyond seven (7) days is necessary. The Contractor will notify the County
immediately if Contractor has knowledge that the person served will require treatment at a facility or is
eloped lasting seven (7) days ormore. A bed hold for non-psychiatric ino|ude, butane not limited to,
medical hospitalization ure|opoment.
In addition to the services listed in "Scope ofVVork` (Exhibit B), Con[ractor shall provide the following
'
BASIC DAILY RATE SERVICES
Basic Daily Rate services consist of usual and cuakomary 8NF/!k8O services to adults with
mental health conditions. Plus those services that are included in Special Treatment ProQnzms
as contained in Title 22 of the California Code of Regulations. sections 72443'72475.
Basic Daily Rate services include reasonable access to required medical treatment, Up-to-date
psych uphannaco|ogy. transportation to needed off-site services and bilingual/bicultural
programming.
Special Treatment Programs (STP) serve persons served who have a chronic psychiatric
impairment and vvhnae adaptive functioning is moderately impaired. These persons served
require condnuous supervisinn and may be expected to benefit from an active rehabilitation
program designed to improve their adaptive functioning or prevent any further deterioration of
their adaptive functioning. Services are provided to individuals having special needs or deficits
in one (1) or more of the following areas: self-help skills, behavioral adjustment: interpersonal
relationships-, pre-vocation preparation, alternative placement planning, and/or pre-release
planning.
U. ENHANCED SERVICES
Enhanced Sen/imaa consist of specialized program services which augment basic services.
Enhanced Gen/|res are designed to serve persons served who have sub-aoute psychiatric
impairment and/or whose adaptive functioning is severely impaired.
EXH|B|TC-4a
Page 2of4
A charge in addition to the Enhanced Services bed rohs may be negotiated on an individual
person served need basis between County'o DBH Director, or designee. and Contractor for
Enhanced and 5TP nen/ioen by using the Special Ben/iceeAuthorizaUon Form (ExhibitG). The
County'o OBH Oirector, or desiQnee, must approve these rates before the person served is
placed or initiation of any enhanced services takes place.
Ui REQUIREMENTS
Contractor shall provide up to thirty-five (35) beds per day for authorized County persons served
during each term of the Agreement. In addition, Contractor shall provide additional beds as
needed by the County. subject to availability of said beds by the Contractor The County does
riot guarantee any minimum number of beds for all services provided by the Contractor and
payment will be based onusage,
|V.
See ~Vista Pacifica Enterprises. INC.. d.b.a. Vista Pacifica Center Rate Table 2022-2023^
attached.
"4U rates other than the Basic Daily Raba must be pre-approved by the County's DBH Dioectnr,
or designee, prior to placement or initiation Of Such services. For any nshs higher than the
Basic Rate Sen/icen, both the rationale and the extra services must be specified and time-
limited and approval must be sought using the Special Services Authorization Form (Exh|bitG)
ora form agreed upon by COUNTY and CONTRACTOR.
'Psychiatric services (provided to persons served placed by Couniy at, 'Contractor's facilities
who are riot covered by Medi-Ca[ private insurance or persona|/otherfunds) shaU be billed
through the Contractor via the monthly service invoice. Psychiatric services biUed by the
service provider on Health Insurance Claim Forms (H|CF 1500) or other forms directly to
County will be rerouted to Contractor for inclusion in monthly invoice. Contractor shall attach
supporting documentation verifying services provided on all psychiatric invoices submit-ted.
Supporting documentation should indude, but are not limited to. date and location of service,
service provided. service duration, name of provider.
Ancillary Outpatient services (|abnratory, x-rays, or other med|cal set-vices performed offsite to a
person served residing in an |W1O/SNF/��,1HRC) must be billed directly to Medi-Ca[ pursuantio
Title 22 of the CCR. County shall be informed and/or approve of any such service(s) to W1edi-
Ca| ineligible persons served in advance of services being provided where possible. Ancillary
charges for non-K4edi'Ca| persons served or non-Med/-Cal billable services may be billed
separately from the monthly service invoice and submitted with supporting documentation to
County.
EXHIBIT C-4a
Page 3 of 4
VISTA PACIFICA ENTERPRISES, INC., d.b.a. VISTA PACIFICA CENTER
Rate Table FY 22-23
Institution of Mental Disease Rates
Services 18-64 Years Old FY 2022-2023
Facility Rate - Daily $ 227.00
Room Reserve Rate $ 227.00
BED HOLD (Leave of absence) $ 218.65**
Private Rate $ 235.00
Augmented Services Rates
Level A (per diem rate in addition to daily rate) $ 70.00 per day
Level B (per diem rate in addition to daily rate) $ 140.00 per day
Level C (per diem rate in addition to daily rate) $ 180.00 per day
Level D (per diem rate in addition to daily rate) $ 160.00 per day
Physician Service SA
Services 65+Years Old FY 2022-2023
Facility Rate - Daily Room Reserve Rate $204.94
BED HOLD (Leave of absence) $196.59**
Private Rate $235.00
Augmented Services Rates
Patch A (per diem rate in addition to daily rate) $90.00 per day
Patch B (per diem rate in addition to daily rate) $160.00 per day
Patch C (per diem rate in addition to daily rate) $200.00 per day
Patch D (per diem rate in addition to daily rate) $180.00 per day
**Bed Hold Rate — Person Served out at Hospital. Above rate will be paid up to seven (7) days without
authorization required.
Room Reserve Rate — Holding bed for person served prior to Admission
EXHIBIT C-4a
Page 4 of 4
REVIEWED AND RECOMMENDED FOR APPROVAL:
B 1�r
Y
S an olt, Director
Department of Behavioral Health
CONTRACTOR:
VISTA PACIFICA ENTERPRISES, INC.,
d.b.a. VISTA PACfICf4 CENTER
By ✓
Print Name:
Title: � v``<`�l � `'•'"
Chairman of the Board, or
President, or any Vice President or
Director of Operations
BY
Print Name: ' )rLz i, 1
Title:
Secretary (o Corporation), or
any Assistant Secretary, or
Chief Financial Officer, or
any Assistant Treasurer/Facility
Administrator
Mailing Address:
3674 Pacifica Avenue
Jurupa Valley, CA 92509
Phone: (951) 682-4833, Ext. 106
Fax: (951) 682-1503
Email: cjumonville@vistapacificaent.com
Contact: Cheryl Jumonville, President
Fund: 0001/10000
Organization: 56302175
Account/Program: 7295/0
REVISED E)(H|BITC-4b
Page 1Of4
DESCRIPTION OF SERVICES & RATES (FY2O22-23)
VISTA PACIF|CA ENTERPRISES, INC, d.b.a. VISTA PACIF!CAC[}0VA[ESCENT
Cnrdnantzr agrees to provide County with Skilled Nursing Facility (SNF) pursuant to Ca|ilonnia'n Welfare
and Institutions Code. Division 5. commencing with section 5000. Title 22 of the California Code of
Regulations, sections 72001. et seq.. the California Department ofHealth Can* San/ioao, Policies and
[}irectives, and other applicable statutes and regulations.
For the purposes of this Agreemnnt, the term "bed day" includes beds held vacant for persons served
who are temporarily [not more than seven (7) days] absent from a facility. An emergency |MD/SNF .
bed-hold for psychiatric and non-psychiatric reasons beyond seven (7) day Must be approved by the
Cnunty'a Department o[ Behavioral Health (DBH) Director, or designee. The County will pay UP to the
first seven (7) bed-hold days and approval must beprovided by the County for any additional days after
connu|Ung with the Contractor. The County will have the final say on a case—by-case basis if on
extended bed-hold of beyond seven (7) days is necessary. The Contractor will notify the County
immediately if Contractor has knowledge that the person served will require treatment at a facility or is
eloped lasting seven (7) days or more. A bed hold for non-psychiatric reasons indude, butane not
limited to, medical hospitalization or elopement.
In addition to the services listed in 'Scope of Work" (Exhibit B). Contractor shall provide the following:
'
BASIC DAILY RATE SERVICES:
Basic Daily Rate services consist ofusual and customary SNF services to adults with medical
and mental health conditions,
Basic Daily Rate services include reasonable access to required medica| Lnsatmenf. Up-to-date
psychopharmaco|ogy. transportation to needed off-site services and bilingual/bicultural
programming.
|i
Enhanced Services consist of specialized program sen/ioes, which augment basic services-
Enhanced Services are designed bnserve persons who have sub-acute psychiatric impairment
and/or whose adaptive functioning ia severely impaired.
A charge in addition to the Enhanced Services bed rate may be negotiated on an individual
person served need basis between the Counb/'s Department of Behavioral Health (DBH)
Dioactor, or designee. and Contractor for Enhanced and Behavioral Services by using the
Special Services Authorization Form (ExhibitG).
Hi
Contractor may provide Lip toforty-nine (49) beds per day for authorized County per-sons served
during each term of the Agncement, as needed by the County, nubjeot to availability of said beds
by the Contractor. The County does not guarantee any minimum number of beds for all
services provided by the Contractor and payment will be based onusage.
REVISED EXHIBIT {_--4b
Page 2mf4
|V.
Program Services Rate
(Rates Effective Upon Expiration of the PUblic Health Emergency)
Facility Rate - Daily Roorn Reserve Rate S243.09
Private Rate - Single $285.00
Augmented Service-, Rate
Patch A (per diem rate in addition to daily rate) $90.00 per day
Patch B (per diem rate in addition to daily rate) $160.00 per day
Patch C (per them rate in addition to daily rate) S200.00 per day
Program Services Rate
(Temporary Increased COVID-19 Rates Effective I/l/2022)**
Facility Rate - Daily Roorn Reserve Rate $264.90
Private Rate - Semi $275.00
Private Rate - Single $285M
Augmented Services Rate
Patch A (per diern rate in addition to daily rate) $70.00 per day
Patch B (Der diern rate in addition to daily rate) $140.00 per day
Patch 11", (per diern rate in addition to daily rate) S 180-00 per day
'The aboveiemponery rates coincide with the Public Health EmerAenoy (PHE) declaration and
the use of these rates shall be terminated upon notice of the State of California that the PHE
has ended.
Room Reserve Rote — Holding bed for person served prior to Admission
Bed Hold Rate — Person Served out at Hospital. Above rate will be paid up to seven (7) days
without authorization required.
^ All rates other than the Basic Daily Rate must be pre-approved by the County's DBH Director.
or designee, prior to placement or initiation of such services. For any rate higher than the
Basic Rate Services, both the rationale and the extra services must be specified end time-
limited and approval Must be sought using the Special Services Authorization Form (ExhibitG)
ora form agreed upon by COUNTY and CONTRACTOR-
^
Psychiatric services (provided to persons served placed by County at Contractor's facilities
who are not covered by Medi'Cai private insurance or personal/other funds) shall be billed
through the Contractor via the monthly service invoice, Psychiatric services billed by the
service provider on Health Insurance Claim Forms (H|CF 1500) or other forms directly to
County will be rerouted to Controckorfor inclusion in monthly invoice. Contractor shall attach
supporting documentation verifying services provided on all psychiatric invoices submitted.
REVISED E)(H|BITC-4b
Page 3mf4
Supporting documentation should indude, but are not limited to, date and location of service,
service provided. service dunabon name ofprovidec
Ancillary outpatient services (laboratory, x-rays, or other medical services performed offsite to a
person served residing in an !MD/SNF/MHRC) must be billed directly to K4edi-Ca[ pursuant to
Title 22 of the CCR. County shall be informed and/or approve of any such service(s) to Medi-
Ca| ineligible persons served in advance of services being provided, vvhens possible. Ancillary
charges for non-K8edi-Cal persons served or non'K8edi'Ca| billable services may be billed
separately from the monthly service invoice and submitted with supporting documentation to
County.
REVISED EXHIBIT C-4b
Page 4 0f
REVIEWED AND RECOMMENDED FOR APPROVAL:
By
an L Holt, Director
Department of Behavioral Health
CONTRACTOR:
VISTA PACIFICA EDIT., INC., d.b.a.
VISTA PACIFICA CO VALE CENT
By
} 1
Print Name,/µ '
Title:
Chairman of the Board, or
President, or any Vice President or
Director oferations
r�
By ,
f
Print Name:
,F
Title: _. - 'r i 'i
Secretary (of Corporatio or
any Assistant Secretary., or
Chief Financial Officer, or
any Assistant Treasurer/Facility
Administrator
Mailing Address:
3662 Pacifica Avenue
Jurupa Valley, CA 92509
Phone: (951) 682-4833, Ext. 106
Fax: (951) 682-1503
Email: cjumonville@vistapacificaent.com
Contact: Cheryl Jumonville, President
Fund: 0001/10000
Organization: 56302175
Account/Program: 7295/0
REVISED EXHIBIT C-5
Pagel of 3
DESCRIPTION OF SERVICES & RATES (FY 2022-23)
HELIOS HEALTHCARE, LLC, d.b.a IDYLWOOD CARE CENTER
Contractor agrees to provide County with Skilled Nursing Facility/Institutions for Mental Disease
(SNF/IMD) services to adult persons served between the ages of 18 to 64 years with mental health
conditions, pursuant to California's Welfare and Institutions Code, section 5900 et seq., Title 22 of the
California Code of Regulations, the California Department of Health Care Services' Policies and
Directives; and other applicable statutes and regulations that apply to the SNF/IMD facilities and
programs.
For the purposes of this Agreement, the term "bed day" includes beds held vacant for persons served
who are temporarily [not more than seven (7) days) absent from a facility. An emergency bed-hold for
psychiatric and non-psychiatric must be approved by the County's Department of Behavioral Health
(DBH) Director, or designee. The County will pay up to the first seven (7) bed-hold days and approval
must be provided by the County by using the Special Services Authorization Form (Exhibit G). The
County will have the final say on a case—by-case basis if an extended bed-hold of beyond seven (7)
days is necessary. The Contractor will notify the County immediately if Contractor has knowledge that
the person served will require treatment at a facility or is eloped lasting seven (7) days or more. A bed
hold for non-psychiatric include, but are not limited to, medical hospitalization or elopement.
In addition to the services listed in "Scope of Work" (Exhibit B), Contractor shall provide the following:
I. ENHANCED SERVICES:
Enhanced Services consist of specialized program services, which augment basic services.
Enhanced Services are designed to serve persons who have sub-acute psychiatric impairment
and/or whose adaptive functioning is severely impaired.
The Enhanced Services bed rate or any other charges in addition to the Enhanced Services bed
rate may be negotiated for a person served on an as-needed basis between County's
Department of Behavioral Health (DBH) Director, or designee, and Contractor. The County's
DBH Director, or designee, must approve these rates before the person served is provided any
services by using the Special Services Authorization Form (Exhibit G).
II. REQUIREMENTS:
Contractor shall provide available beds needed for authorized County persons served during
each term of the Agreement. The County does not guarantee any minimum number of beds for
all services provided by the Contractor and payment will be based on usage.
III. RATES:
The following are the rates per person served per day:
Program Services Rate
Enhanced Services Rate—Tier 1* $125.00 per day
Enhanced Services Rate—Tier 2* $150.00 per day
Enhanced Services Rate—Tier 3* $182.00 per day
1:1 Rate $28.00 per hour
REVISED EXHIBIT C-5
Page 2 of 3
*All rates other than the above listed Enhanced Service Rates must be pre-approved by the
County's DBH Director, or designee, prior to placement or initiation of such services. For any
rate higher than the above listed Enhanced Service Rates, both the rationale and the extra
services must be specified and time-limited and approval must be sought using the Special
Services Authorization Form (Exhibit G).
The identified rates include room and board, nursing care, special treatment program services,
activity program, over-the-counter medications, diet, etc. Physician services, pharmacy and
other ancillary medical services are not included in the per diem rate and are separately billable
in accordance with Title 22, CCR, section 51511 C.
Ancillary outpatient services (laboratory, x-rays, or other medical services performed offsite to a
person served residing in an IMD/SNF/MHRC) must be billed directly to Medi-Cal, pursuant to
Title 22 of the CCR. County shall be informed and/or approve of any such service(s) to Medi-Cal
ineligible persons served in advance of services being provided, where possible. Ancillary
charges for non-Medi- Cal persons served or non-Medi-Cal billable services may be billed
separately from the monthly service invoice and submitted with supporting documentation to
County.
EXHIBIT C-5
Page 3 of 3
REVIEWED AND RECOMMENDED FOR APPROVAL:
By
up�. Ho�fDi�ector
De t of Behavioral Health
CONTRACTOR:
HELIOS HEALTHCARE, LLC, d.b.a
IDYLWOOD CARE CENTER
By &,L-" ,
Print Name: L-&4 A
Title: L��C�CL! �7'�{f-e /►'-� DJ"
Chairman of the Board, or President, or
any Vice President or Director of
Operations � ^ .__ ,��//
Wr��Q
Mailing Address:
520 Capitol Mall, Suite 800
Sacramento, CA 95814
Phone: (916)471-2240
Email: elena.mashkevich@cbhi.net
Contact: Elena Mashkevich
Fund: 0001/10000
Organization: 56302175
Account/Program: 7295/0
REVISED EXHIBIT C-6
Page 1 of 3
DESCRIPTION OF SERVICES & RATES (FY 2022-23)
KP COMMUNITY CARE, LLC., d.b.a. COMMUNITY CARE CENTER
Contractor agrees to provide County with Skilled Nursing Facility/Institutions for Mental Disease
(SNF/IMD) services to adult persons served between the ages of 18 to 64 years with mental health
conditions, pursuant to California's Welfare and Institutions Code, section 5900 et seq., Title 22 of the
California Code of Regulations, the State Department of Health Care Services' Policies and Directives,-
and other applicable statutes and regulations that apply to the SNF/IMD facilities and programs.
For the purposes of this Agreement, the terrti "bed day" includes beds held vacant for persons served
who are temporarily [not more than seven (7) days] absent from a facility. An emergency IMD/SNF
bed-hold for psychiatric and nun-psychiatric reasons beyond seven (7) day must be approved by the
County's Department of Behavioral Health (DBH) Director, or designee. The County will pay up to the
first seven (7) bed-hold days and approval must be provided by the County for any additional days after
consulting with the Contractor. The County will have the final say on a case—by-case basis if an
extended bed-hold of beyond seven (7) days is necessary. The Contractor will notify the County
immediately if Contractor has knowledge that the person served will require treatment at a facility or is
eloped lasting seven (7) days or more. A bed hold for non-psychiatric reasons include, but are not
limited to, medical hospitalization or elopement.
In addition to the services listed in "Scope of Work"(Exhibit B), Contractor shall provide the following:
1. BASIC DAILY RATE SERVICES
Basic Daily Rate services consist of usual and customary SNF/IMD services to adult persons
served with mental health conditions, plus those services that are included in Special Treatment
Programs (STP)as contained in Title 22 of the California Code of Regulations, sections 72448-
72475.
Basic Daily Rate services include reasonable access to required medical treatment, up-to-date
psychopharmacology, transportation to needed off-site services and bilingual/bicultural
programming.
11. ENHANCED SERVICES
Enhanced Services consist of specialized program services which augment basic services.
Enhanced Services are designed to serve persons who have sub-acute psychiatric impairment
and/or whose adaptive functioning is severely impaired.
The Enhanced Services bed rate or any other charges in addition to the Enhanced Services bed
rate may be negotiated for an individual person served on an as-needed basis between
County's Department of Behavioral Health (DBH) Director, or designee, and Contractor. The
County's DBH Director, or designee, must approve these rates before the person served is
provided any services more intensive than the Basic Services. Approval for such services may
be sought using the Special Services Authorization Form(Exhibit G).
III. SUB-ACUTE TREATMENT SERVICES
Sub-acute SNF includes services that are non-acute 24-hour voluntary or involuntary care that
is required for the provision of mental health services to adult persons served with mental health
REVISED EXHIBIT C-6
Page 2 of 3
conditions who are not in need of acute mental health care, but who require general mental
health evaluation, diagnostic assessment, treatment, nursing and/or related services, on a 24-
hour per day basis in order to achieve stabilization and/or an optimal level of functioning. Such
persons served are those who, if in the community, would require the services of a licensed
health facility providing 24-hour sub-acute mental health care. Such facilities include, but are
not limited to, Skilled Nursing Facilities with special treatment programs. Sub-acute has the
same meaning as non-acute as defined in this section.
IV. REQUIREMENTS
Contractor shall provide available beds needed for authorized County persons served during the
term of the Agreement. The County does not guarantee any minimum number of beds for all
services provided by the Contractor and payment will be based on usage.
V. RATES"
Program SieMces Rate
Basic Daily Rate(Bungalow) $410.96 per person served per day
1:1 Supervision (Bungalow) $ 16.52 per hour per person served
Bed Hold (Bungalow) $402.03 per person served per day
Basic Daily Rate (IMD) $287.83 per person served per day
Enhanced Services(IMD) $474.40 per person served per day
Bed Hold (IMD) $278.90 per person served per day
Other Services _ Rage(Range)!Unit
Physician/Psychiatric services;'` $80-$160 per visit
'All rates other than the Basic Daily Rate services must be pre-approved by the County's DBH
Director, or designee, prior to placement or initiation of such services. For any rate higher than
the Basic Rate Services, both the rationale and the extra services must be specified and time-
limited and approval must be sought using the Special Services Authorization Form(Exhibit G).
"Physician/Psychiatric services (provided to persons served placed by County at Contractor's
facilities who are not covered by Medi-Cal, private insurance or personal/other funds) shall be
billed through the Contractor via the monthly service invoice. Psychiatric services billed by the
service provider on Health Insurance Claim Forms (HICF 1500) or other forms directly to County
will be rerouted to Contractor for inclusion in monthly invoice. Contractor shall attach supporting
documentation verifying services provided on all psychiatric invoices submitted. Supporting
documentation should include, but is not limited to, date and location of service, service
provided, service duration, name of provider.
Ancillary outpatient services (laboratory, x-rays, or other medical services performed offsite to a
person served residing in an IMD/SNF/MHRC) must be billed directly to Medi-Cal, pursuant to
Title 22 of the CCR. County shall be informed and/or approve of any such service(s) to Medi-
Cal ineligible persons served in advance of services being provided, where possible. Ancillary
charges for non-Medi-Cal persons served or non-Medi-Cal billable services may be billed
separately from the monthly service invoice and submitted with supporting documentation to
County.
REVISED EXHIBIT C-6
Page 3 of 3
REVIEWED AND RECOMMENDED FOR APPROVAL:
oY _
Susan L Holt, Director
Department of Behavioral Health
CONTRACTOR
KF COMMUNITY CARE, LLC.,
d.b.a.COMMU0�1 Y CARE CE TE
o
By
Print Name: C 1 r 1
Title: kl (VIONft IV��. pbmft-'�
Chairman of the Board, or
President,or any Vice President or
Director of Operatiq
BY
Print Name VN
rrtle: - ,A
Secretary (of orporation), or
any Assistant Secretary, or
Chief Financial Officer, or
any Assistant Treasurer/Facility
Administrator
Mailing Address:
2335 S. Mountain Avenue
Duarte, CA 91010
Phone: (626) 357-3207, Ext. 225
Fax: (626) 303-1116
Emall: Shannon.Bland@huntingtondrivehcc.com
Contact: Shannon Bland, Administrator
Fund: 0001/10000
Organization: 56302175
Acco u n t/P rog ra m: 729 5/0
REVISED EXHIBIT C-7a
Page 1 of 4
DESCRIPTION OF SERVICES & RATES (FY 2022-23)
MORTON BAKAR CENTER, A DIVISION OF TELECARE CORPORATION
Contractor agrees to provide County with Skilled Nursing Facility/Institutions for Mental Disease
(SNF/IMD) services to adult persons served between the ages of 18 to 64 years with mental health
conditions, pursuant to California's Welfare and Institutions Code, section 5900 et seq., Title 22 of the
California Code of Regulations, the State Department of Health Care Services' Policies and Directives;
and other applicable statutes and regulations that apply to the SNF/IMD facilities and programs.
For the purposes of this Agreement, the term "bed day" includes beds held vacant for persons served
who are temporarily [not more than seven (7) days] absent from a facility. An emergency IMD/SNF bed-
hold for psychiatric and non-psychiatric reasons beyond seven (7) day must be approved by the
County's Department of Behavioral Health (DBH) Director, or designee. The County will pay up to the
first seven (7) bed-hold days and approval must be provided by the County for any additional days after
consulting with the Contractor. The County will have the final say on a case—by-case basis if an
extended bed-hold of beyond seven (7) days is necessary. The Contractor will notify the County
immediately if Contractor has knowledge that the person served will require treatment at a facility or is
eloped lasting seven (7) days or more. A bed hold for non-psychiatric reasons include, but are not limited
to, medical hospitalization or elopement.
In addition to the services listed in "Scope of Work" (Exhibit B), Contractor shall provide the following:
I. BASIC DAILY RATE SERVICES:
Basic Daily Rate services consist of usual and customary SNF/IMD services to adult persons
served with mental health conditions, plus those services that are included in Special Treatment
Programs as contained in Title 22 of the California Code of Regulations, sections 72443-72475.
Basic Daily Rate services include reasonable access to required medical treatment, up-to-date
psychopharmacology, transportation to needed off-site services.
II. ENHANCED SERVICES
Enhanced Services consist of specialized program services, which augment basic services.
Enhanced Services are designed to serve persons served who have sub-acute psychiatric
impairment and/or whose adaptive functioning is severely impaired.
A charge in addition to the Enhanced Services bed rate may be negotiated for an individual
person served on an as-needed basis between the County's Department of Behavioral Health
(DBH) Director, or designee, and Contractor. The County's DBH Director, or designee, must
approve these rates before the person served is placed or initiation of any enhanced services
takes place. Approval for such services may be sought using the Special Services Authorization
Form (Exhibit G).
III. REQUIREMENTS
Contractor shall provide available beds for authorized County persons served during each term
of the Agreement. The County does not guarantee any minimum number of beds for all
services provided by the Contractor and payment will be based on usage.
REVISED EXHIBIT C-7a
Page 2 of 4
IV. RATES*
Program Services Rate
Basic Daily Rate (IMD/STP with Medi-Cal) ** $257.20 per person served
Basic Daily Rate (IMD/STP without Medi-Cal) $257.20 per person served
Enhanced Services (with Medi-Cal)** $152.19 per person served
Enhanced Services (without Medi-Cal) $152.19 per person served
Bed Hold Rate $409.39 per person served
1:1 Supervision $39.90 per hour
Other Services Rate/Rate Range
Physician/Psychiatric Services ^ $189.57 per visit
* All rates other than the Basic Daily Rate and Enhanced Services Rate must be
pre-approved by the County's DBH Director, or designee, prior to placement or initiation of
such services. For any rate higher than the Basic Rate Services, or Enhanced Services,
both the rationale and the extra services must be specified and time-limited and approval
must be sought using the Special Services Authorization Form (Exhibit G).
** Rate is set at State Medi-Cal rate and will be adjusted if the Medi-Cal rate changes. In the
event a person served is placed that does not have Medi-Cal and is under age 65, County
will pay both the basic daily rate and the enhanced service rate.
^ Physician/psychiatric services (provided to persons served placed by County at Contractor's
facilities) not covered by Medi-Cal, private insurance or personal/other funds shall be billed
through the Contractor via the monthly service invoice. Psychiatric services billed by the
service provider on Health Insurance Claim Forms (HICF 1500) or other forms directly to
County will be rerouted to Contractor for inclusion in monthly invoice. Contractor shall attach
supporting documentation verifying services provided on all psychiatric invoices submitted.
Supporting documentation should include, but is not limited to, date and location of service,
service provided, service duration, name of provider.
Ancillary outpatient services (laboratory, x-rays, or other medical services performed offsite
to a person served residing in an IMD/SNF/MHRC) must be billed directly to Medi-Cal,
pursuant to Title 22 of the CCR. County shall be informed and/or approve of any such
service(s) to Medi-Cal ineligible persons served in advance of services being provided,
where possible. Ancillary charges for non-Medi-Cal person served or non-Medi-Cal billable
services may be billed separately from the monthly service invoice and submitted with
supporting documentation to County.
V. HOLD HARMLESS
Contractor will adhere to the following Hold Harmless clause, in place of the contract language
stated on Page 11, Paragraph 10, Lines 20 through 27 of this Agreement:
CONTRACTOR agrees to indemnify, save, hold harmless, and at COUNTY's request defend
the COUNTY, its officers, agents and employees from any and all costs and expenses,
including attorney fees and court costs, damages, liabilities, claims and losses occurring or
REVISED EXHIBIT C-7a
Page 3 of 4
resulting to COUNTY in connection with the performance, or failure to perform, by
CONTRACTOR, its officers, agents or employees under this Agreement, and from any and all
costs and expenses, including attorney fees and court costs, damages, liabilities, claims and
losses occurring to or resulting from any person, firm or corporation who may be injured or
damaged by the performance, or failure to perform, of CONTRACTOR, its officers, agents or
employees under this Agreement, excluding, however, such liability, claims, losses, damages,
or expenses arising from COUNTY's sole negligence or willful acts.
REVISED EXHIBIT C-7a
Page 4 of 4
REVIEWED AND RECOMMENDED FOR APPROVAL:
By Ab%*0kr1
Susan L. Holt, Director
Department of Behavioral Health
CONTRACTOR:
MORTON BAKAR CENTER,
A DIVISION OF TELECARE CORPORATION
Y
Print Name: Dawan Utecht
Title: SVP/Chief Development Officer
Chairman of the Board, or
President, or any Vice President or
Director of Operations
&kv MaarhAnn oy
ByKevin Moghanna Au93,2022 14 37 PDT)
Print Name: Kevin Moghannam
Title: Assistant Secretary
Secretary(of Corporation), or
any Assistant Secretary, or
Chief Financial Officer, or
any Assistant Treasurer/Facility
Administrator
Mailing Address:
1080 Marina Village Parkway, Suite 100
Alameda, CA 94501-1043
Phone: (510) 337-7950 Ext. 1183
Fax: (510) 337-7969
Email: dconnolly@telecarecorp.com
Contact: Dwain Connolly, Contracts Analyst
Fund: 0001/10000
Organization: 56302175
Account/Program: 7295/0
REVISED EXHIBIT C-7b
Page 1 of 3
DESCRIPTION OF SERVICES & RATES (FY 2022-23)
CORDILLERAS MENTAL HEALTH REHABILITATION
CENTER (MHRC), A DIVISION OF TELECARE
CORPORATION
Contractor agrees to provide County with Mental Health Rehabilitation Center(MHRC) services for adult
persons served with mental health conditions 18 to 64, pursuant to California's Welfare and Institutions
Code, section 5900 et seq., Title 22 of the California Code of Regulations, the State Department of Health
Care Services' Policies and Directives, Title 9, California Code of Regulations, Division 1, Sub-Chapter
3.5, and other applicable statutes and regulations. Participation in MHRCs is limited to facilities that meet
the licensing and certification requirements of the California Department of Health Services Licensing
and Certification Division.
For the purposes of this Agreement, the term "bed day" includes beds held vacant for persons served
who are temporarily [not more than seven (7) days] absent from a facility. An emergency MHRC bed-
hold for psychiatric and non-psychiatric reasons beyond seven (7)day must be approved by the County's
Department of Behavioral Health (DBH) Director, or designee. The County will pay up to the first seven
(7) bed-hold days and approval must be provided by the County for any additional days after consulting
with the Contractor. The County will have the final say on a case—by-case basis if an extended bed-hold
of beyond seven (7) days is necessary. The Contractor will notify the County immediately if Contractor
has knowledge that the person served will require treatment at a facility or is eloped lasting seven (7)
days or more. A bed hold for non-psychiatric reasons include, but are not limited to, medical
hospitalization or elopement.
In addition to the services listed in "Scope of Work" (Exhibit B), Contractor shall provide the following
I. BASIC DAILY RATE SERVICES
Basic Daily Rate services consist of usual and customary MHRC services to adult persons served
with mental health conditions. Basic Daily Rate services include reasonable access to required
medical treatment, up-to-date psychopharmacology, transportation to needed off-site services
and bilingual/bicultural programming.
II. ENHANCED SERVICES
Enhanced Services consist of specialized program services which augment basic services.
Enhanced Services are designed to serve persons who have sub-acute psychiatric impairment
and/or whose adaptive functioning is severely impaired.
The Enhanced Services bed rate or any other charges in addition to the Enhanced Services bed
rate may be negotiated for an individual person served on an as-needed basis between County's
Department of Behavioral Health (DBH) Director, or designee, and Contractor. The County's DBH
Director, or designee, must approve these rates before the person served is provided any services
more intensive than the Basic Services. Approval for such services may be sought using the
Special Services Authorization Form (Exhibit G).
III. REQUIREMENTS
Contractor shall provide available beds needed for authorized County persons served during
the term of the Agreement. The County does not guarantee any minimum number of beds for
all services provided by the Contractor and payment will be based on usage.
REVISED EXHIBIT C-7b
Page 2 of 3
IV. RATES*
Program Services Rate
Basic Daily Rate (IMD/STP with Medi-Cal) $308.70 per person served
Bed Hold Rate $308.70 per person served
1:1 Supervision $39.90 per hour
Other Services Rate / Rate Range
Physician/Psychiatric Services " $189.27 per visit
* All rates other than the Basic Daily Rate services must be pre-approved by the County's DBH
Director, or designee, prior to placement or initiation of such services. For any rate higher than
the Basic Rate Services, both the rationale and the extra services must be specified and time-
limited and approval must be sought using the Special Services Authorization Form (Exhibit
G).
" Physician/psychiatric services (provided to persons served placed by County at Contractor's
facilities) not covered by Medi-Cal, private insurance or personal/other funds shall be billed
through the Contractor via the monthly service invoice. Psychiatric services billed by the
service provider on Health Insurance Claim Forms (HICF 1500) or other forms directly to
County will be rerouted to Contractor for inclusion in monthly invoice. Contractor shall attach
supporting documentation verifying services provided on all psychiatric invoices submitted.
Supporting documentation should include, but is not limited to, date and location of service,
service provided, service duration, name of provider.
Ancillary outpatient services (laboratory, x-rays, or other medical services performed offsite to
a person served residing in an IMD/SNF/MHRC) must be billed directly to Medi-Cal, pursuant
to Title 22 of the CCR. County shall be informed and/or approve of any such service(s) to
Medi-Cal ineligible persons served in advance of services being provided, where possible.
Ancillary charges for non-Medi-Cal persons served or non-Medi-Cal billable services may be
billed separately from the monthly service invoice and submitted with supporting
documentation to County.
V. HOLD HARMLESS
Contractor will adhere to the following Hold Harmless clause, in place of the contract language
stated on Page 11, Paragraph 10, Lines 20 through 27 of this Agreement:
CONTRACTOR agrees to indemnify, save, hold harmless, and at COUNTY's request defend
the COUNTY, its officers, agents and employees from any and all costs and expenses,
including attorney fees and court costs, damages, liabilities, claims and losses occurring or
resulting to COUNTY in connection with the performance, or failure to perform, by
CONTRACTOR, its officers, agents or employees under this Agreement, and from any and all
costs and expenses, including attorney fees and court costs, damages, liabilities, claims and
losses occurring to or resulting from any person, firm or corporation who may be injured or
damaged by the performance, or failure to perform, of CONTRACTOR, its officers, agents or
employees under this Agreement, excluding, however, such liability, claims, losses, damages,
or expenses arising from COUNTY's sole negligence or willful acts.
REVISED EXHIBIT C-7b
Page 3 of 3
REVIEWED AND RECOMMENDED FOR APPROVAL:
By
Susan L. Holt, Director
Department of Behavioral Health
CONTRACTOR:
CORDILLERAS MENTAL HEALTH CENTER (MHRC),
A DIVISION OF TELECARE CORPORATION
oldBy: D--Ut-ht(AUg-g302 3 2022 15 57 PDT)
Print Name: Dawan Utecht
Title: SVP/Chief Development Officer
Chairman of the Board, or
President, or any Vice President or
Director of Operations
�c 'c�, —By. Kevin Moghanna Aug 3,20221455 PDT)
Print Name: Kevin Moghannam
Title: Assistant Secretary
Secretary (of Corporation), or
any Assistant Secretary, or
Chief Financial Officer, or
any Assistant Treasurer/Facility
Administrator
Mailina Address:
1080 Marina Village Parkway, Suite 100
Alameda, CA 94501-1043
Phone: (510) 337-7950 Ext. 1183
Fax: (510) 337-7969
Email: dconnolly@telecarecorp.com
Contact: Dwain Connolly, Contracts Analyst
Fund: 0001/10000
Organization: 56302175
Account/Program: 7295/0
REVISED EXHIBIT C-7c
Page 1 of 3
DESCRIPTION OF SERVICES & RATES (FY 2022-23)
GLADMAN MENTAL HEALTH REHABILITATION CENTER
(MHRC), A DIVISION OF TELECARE CORPORATION
Contractor agrees to provide County with Mental Health Rehabilitation Center (MHRC) services for adult
persons served with mental health conditions 18 to 64, pursuant to California's Welfare and Institutions
Code, section 5900 et seq., Title 22 of the California Code of Regulations, the State Department of
Health Care Services' Policies and Directives, Title 9, California Code of Regulations, Division 1, Sub-
Chapter 3.5, and other applicable statutes and regulations. Participation in MHRCs is limited to facilities
that meet the licensing and certification requirements of the California Department of Health Services
Licensing and Certification Division.
For the purposes of this Agreement, the term "bed day" includes beds held vacant for persons served
who are temporarily [not more than seven (7) days] absent from a facility. An emergency MHRC bed-
hold for psychiatric and non-psychiatric reasons beyond seven (7) day must be approved by the County's
Department of Behavioral Health (DBH) Director, or designee. The County will pay up to the first seven
(7) bed-hold days and approval must be provided by the County for any additional days after consulting
with the Contractor. The County will have the final say on a case—by-case basis if an extended bed-hold
of beyond seven (7) days is necessary. The Contractor will notify the County immediately if Contractor
has knowledge that the person served will require treatment at a facility or is eloped lasting seven (7)
days or more. A bed hold for non-psychiatric reasons include, but are not limited to, medical
hospitalization or elopement.
In addition to the services listed in "Scope of Work" (Exhibit B), Contractor shall provide the following
I. BASIC DAILY RATE SERVICES
Basic Daily Rate services consist of usual and customary MHRC services to adult persons served
with mental health conditions. Basic Daily Rate services include reasonable access to required
medical treatment, up-to-date psychopharmacology, transportation to needed off-site services and
bilingual/bicultural programming.
II. ENHANCED SERVICES
Enhanced Services consist of specialized program services which augment basic services.
Enhanced Services are designed to serve persons who have sub-acute psychiatric impairment
and/or whose adaptive functioning is severely impaired.
The Enhanced Services bed rate or any other charges in addition to the Enhanced Services
bed rate may be negotiated for an individual person served on an as-needed basis between
County's Department of Behavioral Health (DBH) Director, or designee, and Contractor. The
County's DBH Director, or designee, must approve these rates before the person served is
provided any services more intensive than the Basic Services. Approval for such services may
be sought using the Special Services Authorization Form (Exhibit G).
III. REQUIREMENTS
Contractor shall provide available beds needed for authorized County persons served during the
term of the Agreement. The County does not guarantee any minimum number of beds for all
services provided by the Contractor and payment will be based on usage.
REVISED EXHIBIT C-7c
Page 2 of 3
IV. RATES*
Program Services Rate
Basic Daily Rate (IMD/STP with Medi-Cal) $467.65 per person served
Bed Hold Rate $467.65 per person served
1:1 Supervision $39.90 per hour
Other Services Rate/ Rate Range
Physician/Psychiatric Services ^ $189.27 per visit
* All rates other than the Basic Daily Rate services must be pre-approved by the County's
DBH Director, or designee, prior to placement or initiation of such services. For any rate
higher than the Basic Rate Services, both the rationale and the extra services must be
specified and time-limited and approval must be sought using the Special Services
Authorization Form (Exhibit G).
^ Physician/psychiatric services (provided to persons served placed by County at Contractor's
facilities) not covered by Medi-Cal, private insurance or personal/other funds shall be billed
through the Contractor via the monthly service invoice. Psychiatric services billed by the
service provider on Health Insurance Claim Forms (HICF 1500) or other forms directly to
County will be rerouted to Contractor for inclusion in monthly invoice. Contractor shall attach
supporting documentation verifying services provided on all psychiatric invoices submitted.
Supporting documentation should include, but is not limited to, date and location of service,
service provided, service duration, name of provider.
Ancillary outpatient services (laboratory, x-rays, or other medical services performed offsite
to a person served residing in an IMD/SNF/MHRC) must be billed directly to Medi-Cal,
pursuant to Title 22 of the CCR. County shall be informed and/or approve of any such
service(s) to Medi-Cal ineligible persons served in advance of services being provided,
where possible. Ancillary charges for non-Medi-Cal persons served or non-Medi-Cal billable
services may be billed separately from the monthly service invoice and submitted with
supporting documentation to County.
V. HOLD HARMLESS
Contractor will adhere to the following Hold Harmless clause, in place of the contract language
stated on Page 11, Paragraph 10, Lines 20 through 27 of this Agreement:
CONTRACTOR agrees to indemnify, save, hold harmless, and at COUNTY's request defend
the COUNTY, its officers, agents and employees from any and all costs and expenses,
including attorney fees and court costs, damages, liabilities, claims and losses occurring or
resulting to COUNTY in connection with the performance, or failure to perform, by
CONTRACTOR, its officers, agents or employees under this Agreement, and from any and all
costs and expenses, including attorney fees and court costs, damages, liabilities, claims and
losses occurring to or resulting from any person, firm or corporation who may be injured or
damaged by the performance, or failure to perform, of CONTRACTOR, its officers, agents or
employees under this Agreement, excluding, however, such liability, claims, losses, damages,
or expenses arising from COUNTY's sole negligence or willful acts.
REVISED EXHIBIT C-7c
Page 3 of 3
REVIEWED AND RECOMMENDED FOR APPROVAL:
By AW&W
Susan L. Holt, Director
Department of Behavioral Health
CONTRACTOR:
GLADMAN MENTAL HEALTH REHABILITATION CENTER
(MHRC), A DIVISION OF TELECARE CORPORATION
J...'Ublo-k
By Dawan Utecht(Aug 3,2022 18:52 PDT)
Print Name: Dawan Utecht
Title: SVP/Chief Development Officer
Chairman of the Board, or
President, or any Vice President or
Director of Operations
egV/,!&04I gI�G 'Wt
By Kevin Moghannam Aug4,202208:25 PDT)
Print Name: Kevin Moghannam
Title: Assistant Secretary
Secretary(of Corporation), or
any Assistant Secretary, or
Chief Financial Officer, or
any Assistant Treasurer/Facility
Administrator
Mailing Address:
1080 Marina Village Parkway, Suite 100
Alameda, CA94501-1043
Phone: (510) 337-7950 Ext. 1183
Fax: (510) 337-7969
Email: dconnolly@telecarecorp.com
Contact: Dwain Connolly, Contracts Analyst
Fund: 0001/10000
Organization: 56302175
Account/Program: 7295/0
REVISED EXHIBIT C-7d
Pagel of 4
DESCRIPTION OF SERVICES & RATES (FY 2022-23)
LA PAZ GEROPSYCHIATRIC CENTER,
A DIVISION OF TELECARE CORPORATION
Contractor agrees to provide County with Geropsychiatric Nursing Care Facility (GNCF) services for adult person
served ages 65 years and older with mental health conditions, pursuant to California's Welfare and Institutions
Code, section 5900 et seq., Title 22 of the California Code of Regulations, sections 51335, 71443-72475, and the
California Department of Health Care Services' Policies and Directives, and other applicable statutes and
regulations.
For the purposes of this Agreement, the term "bed day" includes beds held vacant for persons served who are
temporarily (not more than seven (7) days) absent from a facility. For the purposes of this Agreement, the term
"bed day" includes beds held vacant for persons served who are temporarily [not more than seven (7) days]
absent from a facility. An emergency GNCF bed-hold for psychiatric and non-psychiatric reasons beyond seven
(7) day must be approved by the County's Department of Behavioral Health (DBH) Director, or designee. The
County will pay up to the first seven (7) bed-hold days and approval must be provided by the County for any
additional days after consulting with the Contractor. The County will have the final say on a case—by-case basis
if an extended bed-hold of beyond seven (7) days is necessary. The Contractor will notify the County immediately
if Contractor has knowledge that the person served will require treatment at a facility or is eloped lasting seven
(7) days or more. A bed hold for non-psychiatric reasons include, but are not limited to, medical hospitalization or
elopement.
In addition to the services listed in "Scope of Work" (Exhibit B), Contractor shall provide the following
I. BASIC DAILY RATE SERVICES
Basic Daily Rate services consist of usual and customary SNF/IMD services to adult persons served,
ages 65 and older, with mental health conditions, plus those services that are included in Special
Treatment Programs as contained in Title 22 of the California Code of Regulations, sections 72443-
72475.
Basic Daily Rate services include reasonable access to required medical treatment, up-to-date
psychopharmacology, transportation to needed off-site services and bilingual/bicultural programming.
II. ENHANCED SERVICES
Enhanced Services consist of specialized program services which augment basic services. Enhanced
Services are designed to serve persons served who have sub-acute psychiatric impairment and/or whose
adaptive functioning is severely impaired.
A charge in addition to the Enhanced Services bed rate may be negotiated for an individual person
served on an as-needed basis between the County's Department of Behavioral Health (DBH) Director,
or designee, and Contractor. The County's DBH Director, or designee, must approve these rates
before the person served is placed or initiation of any enhanced services takes place. Approval for such
services may be sought using the Special Services Authorization Form (Exhibit G).
III. REQUIREMENTS
Contractor shall provide available beds for authorized County persons served during each term of the
Agreement. The County does not guarantee any minimum number of beds for all services provided by the
Contractor and payment will be based on usage.
REVISED EXHIBIT C-7d
Page 2 of 4
IV. RATES*
Program Services Rate
Basic Daily Rate (IMD/STP with Medi-Cal) ** $204.33 per person served
Basic Daily Rate (IMD/STP without Medi-Cal) $204.33 per person served
Enhanced Services (with Medi-Cal) ** $157.12 per person served
Enhanced Services (without Medi-Cal) $157.12 per person served
Bed Hold Rate $361.45 per person served
1:1 Supervision $39.90 per hour
Other Services Rate / Rate Range
Physician/Psychiatric Services ^ $189.57 per visit
* All rates other than the Basic Daily Rate a n d E n h a n c e d Services R a t e must be
pre-approved by the County's DBH Director, or designee, prior to placement or initiation
of such services. For any rate higher than the Basic Rate Services, or Enhanced Services,
both the rationale and the extra services must be specified and time-limited and approval
must be sought using the Special Services Authorization Form (Exhibit G).
** Rate is set at State Medi-Cal rate and will be adjusted if the Medi-Cal rate changes. In the
event a person served is placed that does not have Medi-Cal and is under age 65, County
will pay both the basic daily rate and the enhanced service rate.
^ Physician/psychiatric services (provided to persons served placed by County at Contractor's
facilities) not covered by Medi-Cal, private insurance or personal/other funds shall be billed
through the Contractor via the monthly service invoice. Psychiatric services billed by the
service provider on Health Insurance Claim Forms (HICF 1500) or other forms directly to
County will be rerouted to Contractor for inclusion in monthly invoice. Contractor shall
attach supporting documentation verifying services provided on all psychiatric invoices
submitted. Supporting documentation should include, but is not limited to, date and location
of service, service provided, service duration, name of provider.
Ancillary outpatient services (laboratory, x-rays, or other medical services performed offsite
to a person served residing in an IMD/SNF/MHRC) must be billed directly to Medi-Cal,
pursuant to Title 22 of the CCR. County shall be informed and/or approve of any such
service(s) to Medi-Cal ineligible persons served in advance of services being provided,
where possible. Ancillary charges for non-Medi-Cal persons served or non-Medi-Cal billable
services may be billed separately from the monthly service invoice and submitted with
supporting documentation to County.
V. HOLD HARMLESS
Contractor will adhere to the following Hold Harmless clause, in place of the contract language
stated on Page 11, Paragraph 10, Lines 20 through 27 of this Agreement:
CONTRACTOR agrees to indemnify, save, hold harmless, and at COUNTY's request defend
the COUNTY, its officers, agents and employees from any and all costs and expenses,
REVISED EXHIBIT C-7d
Page 3 of 4
including attorney fees and court costs, damages, liabilities, claims and losses occurring or
resulting to COUNTY in connection with the performance, or failure to perform, by
CONTRACTOR, its officers, agents or employees under this Agreement, and from any and all
costs and expenses, including attorney fees and court costs, damages, liabilities, claims and
losses occurring to or resulting from any person, firm or corporation who may be injured or
damaged by the performance, or failure to perform, of CONTRACTOR, its officers, agents or
employees under this Agreement, excluding, however, such liability, claims, losses, damages,
or expenses arising from COUNTY's sole negligence or willful acts.
REVISED EXHIBIT C-7d
Page 4 of 4
REVIEWED AND RECOMMENDED FOR APPROVAL:
By
Susan L. Holt, Director
Department of Behavioral Health
CONTRACTOR:
LA PAZ GEROPSYCHIATRIC CENTER,
A DIVISION OF TELECARE CORPORATION
'"IMMU
ByDawan Ute,ht(Aug 3,202214:12 PDT)
Print Name: DaWan UteCht
Title: SVP/Chief Development Officer
Chairman of the Board, or
President, or any Vice President or
Director of Operations
/t-/eyi r Roahaeeaw
By Kevin Moghannam Aug 3,2022 14:36 PDT)
Print Name: Kevin Moghannam
Title: Assistant Secretary
Secretary (of Corporation), or
any Assistant Secretary, or
Chief Financial Officer, or
any Assistant Treasurer/Facility
Administrator
Mailing Address:
Telecare Corporation
1080 Marina Village Parkway, Suite 100
Alameda, CA 94501-1043
Phone: (510) 337-7950 Ext. 1183
Fax: (510) 337-7969
Email: dconnolly@telecarecorp.com
Contact: Dwain Connolly, Director of Financial
Planning & Analysis
Fund: 0001/1000
Organization: 56302175
Account/Program: 7295/0
REVISED EXHIBIT C-7e
Page 1 of 4
DESCRIPTION OF SERVICES & RATES (FY 2022-23)
GARFIELD NEUROBEHAVIORAL CENTER,
A DIVISION OF TELECARE CORPORATION
Contractor agrees to provide County with Skilled Nursing Facility/Institutions for Mental Disease
(SNF/IMD) services to adult persons served between the ages of 18 to 64 years with mental health
conditions, pursuant to California's Welfare and Institutions Code, section 5900 et seq., Title 22 of the
California Code of Regulations, the State Department of Health Care Services' Policies and Directives;
and other applicable statutes and regulations that apply to the SNF/IMD facilities and programs.
For the purposes of this Agreement, the term "bed day" includes beds held vacant for persons served who
are temporarily [not more than seven (7) days] absent from a facility. An emergency IMD/SNF bed-hold
for psychiatric and non-psychiatric reasons beyond seven (7) day must be approved by the County's
Department of Behavioral Health (DBH) Director, or designee. The County will pay up to the first seven
(7) bed-hold days and approval must be provided by the County for any additional days after consulting
with the Contractor. The County will have the final say on a case—by-case basis if an extended bed-hold
of beyond seven (7) days is necessary. The Contractor will notify the County immediately if Contractor has
knowledge that the person served will require treatment at a facility or is eloped lasting seven (7) days or
more. A bed hold for non-psychiatric reasons include, but are not limited to, medical hospitalization or
elopement.
In addition to the services listed in "Scope of Work" (Exhibit B), Contractor shall provide the following:
I. BASIC DAILY RATE SERVICES:
Basic Daily Rate services consist of usual and customary SNF/IMD services to adult persons
served with mental health conditions, plus those services that are included in Special Treatment
Programs as contained in Title 22 of the California Code of Regulations, sections 72443-72475.
Basic Daily Rate services include reasonable access to required medical treatment, up-to-date
psychopharmacology, transportation to needed off-site services and bilingual/bicultural
programming.
II. ENHANCED SERVICES
Enhanced Services consist of specialized program services, which augment basic services.
Enhanced Services are designed to serve persons served who have sub-acute psychiatric
impairment and/or whose adaptive functioning is severely impaired.
A charge in addition to the Enhanced Services bed rate may be negotiated for an individual
person served on an as-needed basis between the County's Department of Behavioral Health
(DBH) Director, or designee, and Contractor. The County's DBH Director, or designee, must
approve these rates before the person served is placed or initiation of any enhanced services
takes place. Approval for such services may be sought using the Special Services Authorization
Form (Exhibit G).
III. REQUIREMENTS
Contractor shall provide available beds for authorized County persons served during the term of
the Agreement. The County does not guarantee any minimum number of beds for all services
provided by the Contractor and payment will be based on usage.
REVISED EXHIBIT C-7e
Page 2 of 4
IV. RATES*
Program Services Rate
Basic Daily Rate (IMD/STP with Medi-Cal)** $384.13 per person served
Basic Daily Rate (IMD/STP without Medi-Cal) $384.13 per person served
Enhanced Services (with Medi-Cal)** $293.49 per person served
Enhanced Services (without Medi-Cal) $293.49 per person served
Bed Hold Rate $677.62 per person served
1:1 Supervision $39.90 per hour
Other Services Rate/Rate Range
Physician/Psychiatric Services ^ $189.57 per visit
* All rates other than the Basic Daily Rate and Enhanced Services Rate must be
pre-approved by the County's DBH Director, or designee, prior to placement or initiation of
such services. For any rate higher than the Basic Rate Services, or Enhanced Services, both
the rationale and the extra services must be specified and time-limited and approval must be
sought using the Special Services Authorization Form (Exhibit G).
** Rate is set at State Medi-Cal rate and will be adjusted if the Medi-Cal rate changes. In the
event a person served is placed that does not have Medi-Cal and is under age 65, County
will pay both the basic daily rate and the enhanced service rate.
^ Physician/psychiatric services (provided to persons served placed by County at Contractor's
facilities) not covered by Medi-Cal, private insurance or personal/other funds shall be billed
through the Contractor via the monthly service invoice. Psychiatric services billed by the
service provider on Health Insurance Claim Forms (HICF 1500) or other forms directly to
County will be rerouted to Contractor for inclusion in monthly invoice. Contractor shall attach
supporting documentation verifying services provided on all psychiatric invoices submitted.
Supporting documentation should include, but is not limited to, date and location of service,
service provided, service duration, name of provider.
Ancillary outpatient services (laboratory, x-rays, or other medical services performed offsite
to a person served residing in an IMD/SNF/MHRC) must be billed directly to Medi-Cal,
pursuant to Title 22 of the CCR. County shall be informed and/or approve of any such
service(s) to Medi-Cal ineligible persons served in advance of services being provided,
where possible. Ancillary charges for non-Medi-Cal persons served or non-Medi-Cal billable
services may be billed separately from the monthly service invoice and submitted with
supporting documentation to County.
V. HOLD HARMLESS
Contractor will adhere to the following Hold Harmless clause, in place of the contract language
stated on Page 11, Paragraph 10, Lines 20 through 27 of this Agreement:
CONTRACTOR agrees to indemnify, save, hold harmless, and at COUNTY's request defend
the COUNTY, its officers, agents and employees from any and all costs and expenses,
including attorney fees and court costs, damages, liabilities, claims and losses occurring or
resulting to COUNTY in connection with the performance, or failure to perform, by
REVISED EXHIBIT C-7e
Page 3 of 4
CONTRACTOR, its officers, agents or employees under this Agreement, and from any and all
costs and expenses, including attorney fees and court costs, damages, liabilities, claims and
losses occurring to or resulting from any person, firm or corporation who may be injured or
damaged by the performance, or failure to perform, of CONTRACTOR, its officers, agents or
employees under this Agreement, excluding, however, such liability, claims, losses, damages,
or expenses arising from COUNTY's sole negligence or willful acts.
REVISED EXHIBIT C-7e
Page 4 of 4
REVIEWED AND RECOMMENDED FOR APPROVAL:
By AW9W
Susan L. Holt, Director
Department of Behavioral Health
CONTRACTOR
GARFIELD NEUROBEHAVIORAL CENTER,
A DIVISION OF TELECARE CORPORATION
ByDawan Utecht(7ug3,202214:34 PDT)
Print Name: Dawan Utecht
Title: SVP/Chief Development Officer
Chairman of the Board, or
President, or any Vice President or
Director of Operations
By egVi�&ahGt`!�lGll�1
Kevin Moghannam Aug 3,202214:36 PDT)
Print Name: Kevin Moghannam
Title: Assistant Secretary
Secretary(of Corporation), or
any Assistant Secretary, or
Chief Financial Officer, or
any Assistant Treasurer/Facility
Administrator
Mailing Address:
1080 Marina Village Parkway, Suite 100
Alameda, CA 94501-1043
Phone: (510) 337-7950 Ext. 1183
Fax: (510) 337-7969
Email: dconnolly@telecarecorp.com
Contact: Dwain Connolly, Contracts Analyst
Fund: 0001/10000
Organization: 56302175
Account/Program: 7295/0
REVISED EXHIBIT C-7f
Page 1 of 3
DESCRIPTION OF SERVICES & RATES (FY 2022-23)
VILLA FAIRMONT MENTAL HEALTH REHABILITATION CENTER
(MHRC), A DIVISION OF TELECARE CORPORATION
Contractor agrees to provide County with Mental Health Rehabilitation Center (MHRC) services for
adult persons served with mental health conditions 18 to 64, pursuant to California's Welfare and
Institutions Code, section 5900 et seq., Title 22 of the California Code of Regulations, the State
Department of Health Care Services' Policies and Directives, Title 9, California Code of Regulations,
Division 1, Sub-Chapter 3.5, and other applicable statutes and regulations. Participation in MHRCs is
limited to facilities that meet the licensing and certification requirements of the California Department of
Health Care Services Licensing and Certification Division.
For the purposes of this Agreement, the term "bed day" includes beds held vacant for persons served
who are temporarily [not more than seven (7) days] absent from a facility. An emergency MHRC bed-
hold for psychiatric and non-psychiatric reasons beyond seven (7) day must be approved by the
County's Department of Behavioral Health (DBH) Director, or designee. The County will pay up to the
first seven (7) bed-hold days and approval must be provided by the County for any additional days after
consulting with the Contractor. The County will have the final say on a case—by-case basis if an
extended bed-hold of beyond seven (7) days is necessary. The Contractor will notify the County
immediately if Contractor has knowledge that the person served will require treatment at a facility or is
eloped lasting seven (7) days or more. A bed hold for non-psychiatric reasons include, but are not
limited to, medical hospitalization or elopement.
In addition to the services listed in "Scope of Work" (Exhibit B), Contractor shall provide the following
I. BASIC DAILY RATE SERVICES
Basic Daily Rate services consist of usual and customary MHRC services to adult persons
served with mental health conditions. Basic Daily Rate services include reasonable access to
required medical treatment, up-to-date psychopharmacology, transportation to needed off-site
services and bilingual/bicultural programming.
II. ENHANCED SERVICES
Enhanced Services consist of specialized program services which augment basic services.
Enhanced Services are designed to serve persons who have sub-acute psychiatric impairment
and/or whose adaptive functioning is severely impaired.
The Enhanced Services bed rate or any other charges in addition to the Enhanced Services bed
rate may be negotiated for an individual person served on an as-needed basis between
County's Department of Behavioral Health (DBH) Director, or designee, and Contractor. The
County's DBH Director, or designee, must approve these rates before the person served is
provided any services more intensive than the Basic Services. Approval for such services may
be sought using the Special Services Authorization Form (Exhibit G).
III. REQUIREMENTS
Contractor shall provide available beds needed for authorized County persons served during the
term of the Agreement. The County does not guarantee any minimum number of beds for all
services provided by the Contractor and payment will be based on usage.
REVISED EXHIBIT C-7f
Page 2 of 3
IV. RATES*
Program Services Rate
Basic Daily Rate (IMD/STP with Medi-Cal) $458.96 per person served
Enhanced Services(with Medi-Cal) $458.96 per person served
Bed Hold Rate $458.96 per person served
Other Services Rate/ Rate Range
Physician/Psychiatric Services ^ $189.27 per visit
* All rates other than the Basic Daily Rate services must be pre-approved by the County's
DBH Director, or designee, prior to placement or initiation of such services. For any rate
higher than the Basic Rate Services, both the rationale and the extra services must be
specified and time-limited and approval must be sought using the Special Services
Authorization Form (Exhibit G).
^ Physician/psychiatric services (provided to persons served placed by County at Contractor's
facilities) not covered by Medi-Cal, private insurance or personal/other funds shall be billed
through the Contractor via the monthly service invoice. Psychiatric services billed by the
service provider on Health Insurance Claim Forms (HICF 1500) or other forms directly to
County will be rerouted to Contractor for inclusion in monthly invoice. Contractor shall attach
supporting documentation verifying services provided on all psychiatric invoices submitted.
Supporting documentation should include, but is not limited to, date and location of service,
service provided, service duration, name of provider.
Ancillary outpatient services (laboratory, x-rays, or other medical services performed offsite
to a person served residing in an IMD/SNF/MHRC) must be billed directly to Medi-Cal,
pursuant to Title 22 of the CCR. County shall be informed and/or approve of any such
service(s) to Medi-Cal ineligible persons served in advance of services being provided,
where possible. Ancillary charges for non-Medi-Cal persons or non-Medi-Cal billable
services may be billed separately from the monthly service invoice and submitted with
supporting documentation to County.
V. HOLD HARMLESS
Contractor will adhere to the following Hold Harmless clause, in place of the contract language
stated on Page 11, Paragraph 10, Lines 20 through 27 of this Agreement:
CONTRACTOR agrees to indemnify, save, hold harmless, and at COUNTY's request defend
the COUNTY, its officers, agents and employees from any and all costs and expenses,
including attorney fees and court costs, damages, liabilities, claims and losses occurring or
resulting to COUNTY in connection with the performance, or failure to perform, by
CONTRACTOR, its officers, agents or employees under this Agreement, and from any and all
costs and expenses, including attorney fees and court costs, damages, liabilities, claims and
losses occurring to or resulting from any person, firm or corporation who may be injured or
damaged by the performance, or failure to perform, of CONTRACTOR, its officers, agents or
employees under this Agreement, excluding, however, such liability, claims, losses, damages,
or expenses arising from COUNTY's sole negligence or willful acts.
REVISED EXHIBIT C-7f
Page 3 of 3
REVIEWED AND RECOMMENDED FOR APPROVAL:
BY .AAW�
Susan L. Holt, Director
Department of Behavioral Health
CONTRACTOR:
VILLA FAIRMONT MENTAL HEALTH REHABILITATION CENTER
(MHRC), A DIVISION OF TELECARE CORPORATION
By Daw—n Utecht(Aug 3,202217:41 PDT)
Print Name: Dawan Utecht
Title: SVP/Chief Development Officer
Chairman of the Board, or
President, or any Vice President or
Director of Operations
By Kevin Moghan nam Aug4,202208:24 PDT)
Print Name: Kevin Moghannam
Title: Assistant Secretary
Secretary(of Corporation), or
any Assistant Secretary, or
Chief Financial Officer, or
any Assistant Treasurer/Facility
Administrator
Mailing Address:
1080 Marina Village Parkway, Suite 100
Alameda, CA 94501-1043
Phone: (510) 337-7950 Ext. 1183
Fax: (510) 337-7969
Email: dconnolly@telecarecorp.com
Contact: Dwain Connolly, Contracts Analyst
Fund: 0001/10000
Organization: 56302175
Account/Program: 7295/0
REVISED EXHIBIT C-7g
Page 1 of 3
DESCRIPTION OF SERVICES & RATES (FY 2022-23)
VILLA FAIRMONT (MHRC) - FLEX UNIT,
A DIVISION OF TELECARE CORPORATION
Contractor agrees to provide County with Mental Health Rehabilitation Center (MHRC) services for adult
persons served with mental health conditions 18 to 64, pursuant to California's Welfare and Institutions
Code, section 5900 et seq., Title 22 of the California Code of Regulations, the State Department of Health
Care Services' Policies and Directives, Title 9, California Code of Regulations, Division 1, Sub-Chapter
3.5, and other applicable statutes and regulations. Participation in MHRCs is limited to facilities that meet
the licensing and certification requirements of the California Department of Health Care Services
Licensing and Certification Division.
For the purposes of this Agreement, the term "bed day" includes beds held vacant for persons served
who are temporarily (not more than seven (7) days) absent from a facility. An emergency MHRC bed-
hold for psychiatric and non-psychiatric reasons beyond seven (7)day must be approved by the County's
Department of Behavioral Health (DBH) Director, or designee. The County will pay up to the first seven
(7) bed-hold days and approval must be provided by the County for any additional days after consulting
with the Contractor. The County will have the final say on a case—by-case basis if an extended bed-hold
of beyond seven (7) days is necessary. The Contractor will notify the County immediately if Contractor
has knowledge that the person served will require treatment at a facility or is eloped lasting seven (7)
days or more. A bed hold for non-psychiatric reasons include, but are not limited to, medical
hospitalization or elopement.
In addition to the services listed in "Scope of Work" (Exhibit B), Contractor shall provide the following
I. BASIC DAILY RATE SERVICES
Basic Daily Rate services consist of usual and customary MHRC services to adult persons served
with mental health conditions. Basic Daily Rate services include reasonable access to required
medical treatment, up-to-date psychopharmacology, transportation to needed off-site services
and bilingual/bicultural programming.
II. ENHANCED SERVICES
Enhanced Services consist of specialized program services which augment basic services.
Enhanced Services are designed to serve persons who have sub-acute psychiatric impairment
and/or whose adaptive functioning is severely impaired.
The Enhanced Services bed rate or any other charges in addition to the Enhanced Services bed
rate may be negotiated for an individual person served on an as-needed basis between County's
Department of Behavioral Health (DBH) Director, or designee, and Contractor. The County's DBH
Director, or designee, must approve these rates before the person served is provided any services
more intensive than the Basic Services. Approval for such services may be sought using the
Special Services Authorization Form (Exhibit G).
III. REQUIREMENTS
Contractor shall provide available beds needed for authorized County persons served during the
term of the Agreement. The County does not guarantee any minimum number of beds for all
services provided by the Contractor and payment will be based on usage.
REVISED EXHIBIT C-7g
Page 2 of 3
IV. RATES*
Program Services Rate
Basic Daily Rate (IMD/STP with Medi-Cal) $520.00 per person served
Enhanced Services(with Medi-Cal) $520.00 per person served
Bed Hold Rate $520.00 per person served
Other Services Rate/ Rate Range
Physician/Psychiatric Services " $189.27 per visit
* All rates other than the Basic Daily Rate services must be pre-approved by the County's
DBH Director, or designee, prior to placement or initiation of such services. For any rate higher
than the Basic Rate Services, both the rationale and the extra services must be specified and
time-limited and approval must be sought using the Special Services Authorization Form
(Exhibit G).
^ Physician/psychiatric services (provided to persons served placed by County at Contractor's
facilities) not covered by Medi-Cal, private insurance or personal/other funds shall be billed
through the Contractor via the monthly service invoice. Psychiatric services billed by the
service provider on Health Insurance Claim Forms (HICF 1500) or other forms directly to
County will be rerouted to Contractor for inclusion in monthly invoice. Contractor shall attach
supporting documentation verifying services provided on all psychiatric invoices submitted.
Supporting documentation should include, but is not limited to, date and location of service,
service provided, service duration, name of provider.
Ancillary outpatient services (laboratory, x-rays, or other medical services performed offsite to
a person served residing in an IMD/SNF/MHRC) must be billed directly to Medi-Cal, pursuant
to Title 22 of the CCR. County shall be informed and/or approve of any such service(s) to
Medi-Cal ineligible persons served in advance of services being provided, where possible.
Ancillary charges for non-Medi-Cal persons served or non-Medi-Cal billable services may be
billed separately from the monthly service invoice and submitted with supporting
documentation to County.
V. HOLD HARMLESS
Contractor will adhere to the following Hold Harmless clause, in place of the contract language
stated on Page 11, Paragraph 10, Lines 20 through 27 of this Agreement:
CONTRACTOR agrees to indemnify, save, hold harmless, and at COUNTY's request defend
the COUNTY, its officers, agents and employees from any and all costs and expenses,
including attorney fees and court costs, damages, liabilities, claims and losses occurring or
resulting to COUNTY in connection with the performance, or failure to perform, by
CONTRACTOR, its officers, agents or employees under this Agreement, and from any and all
costs and expenses, including attorney fees and court costs, damages, liabilities, claims and
losses occurring to or resulting from any person, firm or corporation who may be injured or
damaged by the performance, or failure to perform, of CONTRACTOR, its officers, agents or
employees under this Agreement, excluding, however, such liability, claims, losses, damages,
or expenses arising from COUNTY's sole negligence or willful acts.
REVISED EXHIBIT C-7g
Page 3 of 3
REVIEWED AND RECOMMENDED FOR APPROVAL:
By AWd*�
Susan L. Holt, Director
Department of Behavioral Health
CONTRACTOR:
VILLA FAIRMONT (MHRC)— FLEX UNIT,
A DIVISION OF TELECARE CORPORATION
B d�1&&*
y +,,Utecht lAug3 202214:33 PDT)
Print Name: Dawan Utecht
Title: SVP/Chief Development Officer
Chairman of the Board, or
President, or any Vice President or
Director of Operations
/Kel-/�/ti1o�Grg��a�r
By Kevin Moghannam Aug 3,202214:38 PDT)
Print Name: Kevin Moghannam
Title: Assistant Secretary
Secretary(of Corporation), or
any Assistant Secretary, or
Chief Financial Officer, or
any Assistant Treasurer/Facility
Administrator
Mailing Address:
1080 Marina Village Parkway, Suite 100
Alameda, CA94501-1043
Phone: (510) 337-7950 Ext. 1183
Fax: (510) 337-7969
Email: dconnolly@telecarecorp.com
Contact: Dwain Connolly, Contracts Analyst
Fund: 0001/10000
Organization: 56302175
Account/Program: 7295/0
EXHIBIT C-8
Page 1 of 3
DESCRIPTION OF SERVICES & RATES (FY 2022-23)
MENTAL HEALTH MANAGEMENT I, INC., d.b.a. CANYON MANOR
Contractor agrees to provide County with Mental Health Rehabilitation Center (MHRC) services for
adults with mental health conditions 18 to 64, pursuant to California's Welfare and Institutions Code,
section 5900 et seq., Title 22 of the California Code of Regulations, the State Department of Health
Care Services' Policies and Directives, Title 9, California Code of Regulations, Division 1, Sub-Chapter
3.5, and other applicable statutes and regulations. Participation in MHRCs is limited to facilities that
meet the licensing and certification requirements of the California Department of Health Services
Licensing and Certification Division.
For the purposes of this Agreement, the term "bed day" includes beds held vacant for clients who are
temporarily (not more than seven (7) days) absent from a facility. A bed-hold day cannot be in place
when the client is in a psychiatric health facility (PHF) or any acute hospital for psychiatric reasons. A
bed hold can only be placed for non-psychiatric reasons, e.g., medical hospitalization.
In addition to the services listed in "Scope of Work" (Exhibit B), Contractor shall provide the following:
I. BASIC DAILY RATE SERVICES
Basic Daily Rate services consist of usual and customary MHRC services to adults with mental
health conditions. Basic Daily Rate services include reasonable access to required medical
treatment, up-to-date psychopharmacology, transportation to needed off-site services and
bilingual/bicultural programming.
II. ENHANCED SERVICES
Enhanced Services consist of specialized program services which augment basic services.
Enhanced Services are designed to serve clients who have sub-acute psychiatric impairment
and/or whose adaptive functioning is severely impaired.
The Enhanced Services bed rate or any other charges in addition to the Enhanced Services bed
rate may be negotiated for an individual client on an as-needed basis between County's
Department of Behavioral Health (DBH) Director, or designee, and Contractor. The County's
DBH Director, or designee, must approve these rates before the client is provided any services
more intensive than the Basic Services. Approval for such services may be sought using the
Special Services Authorization Form (Exhibit G).
III. REQUIREMENTS
Contractor shall provide available beds needed for authorized County clients during the term of
this Agreement. The County does not guarantee any minimum number of beds.
EXHIBIT C-8
Page 2 of 3
IV. RATES
Program Services Rate
Basic Daily Rate* $366.06
Other Services Rate
One on One Rate per 8 hour Shift^ $435.34
* The Basic Daily Rate shall be inclusive of all psychiatric services such as weekly visits, initial
psychiatric assessment and two affidavits for LPS conservatorship renewal per year.
^ Only applicable for those counties contracted for one on one services.
"Any rates other than the Basic Daily Rate services must be pre-approved by the County's
DBH Director, or designee, prior to placement or initiation of such services. For any rate higher
than the Basic Rate Services, both the rationale and the extra services must be specified and
time-limited and approval must be sought using the Special Services Authorization Form
(Exhibit G).
Ancillary outpatient services (laboratory, x-rays, or other medical services performed offsite to a
client residing in an IMD/SNF/MHRC) must be billed directly to Medi-Cal, pursuant to Title 22 of
the CCR. County shall be informed and/or approve of any such service(s) to Medi-Cal ineligible
clients in advance of services being provided, where possible. Ancillary charges for non-Medi-
Cal clients or non-Medi-Cal billable services may be billed separately from the monthly service
invoice and submitted with supporting documentation to County.
EXHIBIT C-8
Page 3 of 3
REVIEWED AND RECOMMENDED FOR APPROVAL:
By
Susan Ho , Director
Department of Behavioral Health
CONTRACTOR:
MENTAL HEALTH MANAGEMENT I, INC.,
d.b.a. CANYON MANOR
B
Title: Z)i re-c--�o(-
Chairman of the Board, or
President, or any Vice President or
Director of Operations
By 6'
rr Name:,JOQrn Z-,6r1
Title:51- Q CCou
Secretary (of Corporatii , or
any Assistant Secretary, or
Chief Financial Officer, or
any Assistant Treasurer/Facility
Administrator
Mailing Address:
655 Canyon Manor Road
Novato, CA 94947
Phone: (415) 892-1628
Fax: (415) 892-8624
Email: Paul.Heil@canyonmanor.com
Contact: Paul Heil, Executive Director
Fund: 0001/10000
Organization: 56302175
Account/Program: 7295/0
REVISED EXHIBIT C-9
Page 1 of 4
DESCRIPTION OF SERVICES & RATES (FY 2022-23)
OAKLANDIDENCE OPCO, LLC., d.b.a. MEDICAL HILL HEALTHCARE CENTER
Contractor agrees to provide County with Skilled Nursing Facility/Institutions for Mental Disease
(SNF/IMD) services to adult persons served ages 18 to 64 years with mental health conditions,
pursuant to Welfare and Institutions Code, section 5900, et seq., Title 22 of the California Code of
Regulations, the California Department of Health Care Services' Policies and Directives, and other
applicable statutes and regulations. In addition, Contractor agrees to provide County with
Geropsychiatric Nursing Care Facility (GNCF) services for adult persons served age 65 years and older
with mental health conditions, pursuant to California's Welfare and Institutions Code, section 5900 of
seq., Title 22 of the California Code of Regulations, sections 51335, 71443-72475, and the California
Department of Health Care Services' Policies and Directives, and other applicable statutes and
regulations.
For the purposes of this Agreement, the term "bed day" includes beds held vacant for persons served
who are temporarily [not more than seven (7) days] absent from a facility. An emergency bed-hold for
psychiatric and non-psychiatric reasons beyond seven (7) day must be approved by the County's
Department of Behavioral Health (DBH) Director, or designee. The County will pay up to the first seven
(7) bed-hold days and approval must be provided by the County for any additional days after consulting
with the Contractor. The County will have the final say on a case—by-case basis if an extended bed-hold
of beyond seven (7) days is necessary. The Contractor will notify the County immediately if Contractor
has knowledge that the person served will require treatment at a facility or is eloped lasting seven (7)
days or more. A bed hold for non-psychiatric reasons include, but are not limited to, medical
hospitalization or elopement.
In addition to the services listed in "Scope of Work" (Exhibit B), Contractor shall provide the following:
I. BASIC DAILY RATE SERVICES
Basic Daily Rate services consist of usual and customary GNCF services to adult persons
served ages 65 and older with mental health conditions as an alternative to State hospitalization
or other higher levels of care. In addition, contractor will provide SNF/IMD services to adult
persons served ages 18 to 64 years of age with mental health conditions.
Services shall be provided in a secure, skilled nursing facility located at 475 Twenty-Ninth
Street, Oakland, CA 94609, which offers twenty-four (24) hour care and staffing. Contractor
shall, in conjunction with County, develop and implement a treatment plan, using resources
available to both Contractor and County.
Contractor shall provide appropriate activities for County persons served and ongoing
consultation with the County DBH's Older Adult Team.
Contractor shall use its best efforts to facilitate each person's served transfer to a lower level of
care, through collaboration with County.
Contractor shall ensure that the County Public Guardian receives two (2) physician's
declarations required to renew LPS Conservatorships at least forty-five (45) days prior to the
expiration of the conservatorship term.
REVISED EXHIBIT C-9
Page 2 of 4
Basic Daily Rate services include reasonable access to required medical treatment, up-to-date
psychopharmacology, transportation to needed off-site services, and bilingual/bicultural
programming as appropriate.
II. SPECIAL TREATMENT PROGRAMS
Special Treatment Programs (STP) serve persons who have a chronic psychiatric impairment
and whose adaptive functioning is moderately impaired. These persons served require
continuous supervision and may be expected to benefit from an active rehabilitation program
designed to improve their adaptive functioning or prevent any further deterioration of their
adaptive functioning. Services are provided to persons served having special needs or deficits
in one (1) or more of the following areas: self-help skills; behavioral adjustment; interpersonal
relationships; pre-vocation preparation, alternative placement planning, and pre-release
planning.
Ill. ENHANCED SERVICES
Enhanced Services augment the services of Basic and Special Treatment Programs. Enhanced
Services are designed to serve persons who have sub-acute psychiatric impairment and/or
whose adaptive functioning is severely impaired.
The target population includes adult persons served with serious and persistent mental health
conditions whose behavior requires more intensive programming than is available from Basic
Services. It is anticipated that the intensive treatment and staffing provided by enhanced
services will prevent State Hospital admissions. The target population may include persons
served who are often at risk of elopement and occasionally assaultive or self-destructive. They
may have complicating medical problems. Additionally, they may require specialized services to
insure successful transition to community living.
The major objectives for these services are: to control and modify the person's served
destructive behavior; and, to prevent or reduce acute psychiatric hospitalization or long-term
State hospitalization.
IV. REQUIREMENTS
All persons served designated to receive enhanced services shall be approved in writing by the
County's Department of Behavioral Health (DBH) Director, or designee, prior to the
implementation of said enhanced services at the time of placement. If the services of a person
housed in the facility has a need to increase the level of care from Basic to Enhanced services a
prior approval must be obtained from the County's DBH Director, or designee, utilizing the
Special Services Authorization Form (Exhibit G). Any emergency provision of enhanced
services will need a written authorization within five (5)working days of any oral authorization.
The above bed requirements are based on average use and County does not guarantee any
minimum bed days. Payment will only be made for beds utilized.
Upon mutual oral consent of the Contractor and County's DBH Director, or designee, Contractor
shall accept and place into Contractor's facility all persons served referred by County. County
shall coordinate the placement of persons served with Contractor's admission staff.
REVISED EXHIBIT C-9
Page 3 of 4
V. RATES*
Program Services Rate
Basic Daily Rate (IMD/STP with Medi-Cal) $200 per person served per day
SNF Geropsychiatric Bed
Basic Daily Rate (IMD/STP without Medi-Cal) $400 per person served per day
SNF Geropsychiatric Bed _
Enhanced Services (with Medi-Cal) $350 per person served per day (pre-authorization
SNF Geropsychiatric Bed (STP) required)
Enhanced Services (without Medi-Cal) $550 per person served per day (pre-authorization
SNF Geropsychiatric Bed (Enhanced) required)
Bed Hold Rate $200 per person served per day
Other Services Rate (Range)
Physician Services— $80 per visit
*All rates other than the Basic Daily Rate services must be pre-approved by the County's DBH
Director, or designee, prior to placement or initiation of such services. For any rate higher than
the Basic Rate Services, both the rationale and the extra services must be specified and time-
limited and approval must be sought using the Special Services Authorization Form (Exhibit G).
**Physician/Psychiatric services (provided to persons served placed by County at Contractor's
facilities who are not covered by Medi-Cal, private insurance or personal/other funds) shall be
billed through the Contractor via the monthly service invoice. Psychiatric services billed by the
service provider on Health Insurance Claim Forms (HICF 1500) or other forms directly to County
will be rerouted to Contractor for inclusion in monthly invoice. Contractor shall attach supporting
documentation verifying services provided on all psychiatric invoices submitted. Supporting
documentation should include, but is not limited to, date and location of service, service
provided, service duration, name of provider.
Ancillary outpatient services (laboratory, x-rays, or other medical services performed offsite to a
client residing in an IMD/SNF/MHRC) must be billed directly to Medi-Cal, pursuant to Title 22 of
the CCR. County shall be informed and/or approve of any such service(s) to Medi-Cal ineligible
persons served in advance of services being provided, where possible. Ancillary charges for
non-Medi-Cal persons served or non-Medi-Cal billable services may be billed separately from
the monthly service invoice and submitted with supporting documentation to County.
REVISED EXHIBIT C-9
Page 4 of 4
REVIEWED AND RECOMMENDED FOR APPROVAL:
By
Susan L H erector
Department of Behavioral Health
CONTRACTOR:
OAKLANDIDENCE OPCO, LLC.
d.b.a. MEDI L ILL HEALTHCARE CENTER
By
Print Name: SZ?e lmy- 3f kA, Oyl
Title: iV-eokpr 0 O10eCrw ,gvj S
Chairman of the Board, or
President, or any Vice President or
Director of Operations
By
Print Name: ���
Title: M K I A ST( f
Secretary (of Corporation), or
any Assistant Secretary, or
Chief Financial Officer, or
any Assistant Treasurer/Facility
Administrator
Mailing Address:
475 29'" Street
Oakland, CA 94609
Phone: (661) 886-9249
Fax:
Email: andrew.snider@mcclurepa.com
Contact: Andrew Snider, Administrator
Fund: 0001/10000
Organization: 56302175
Account/Program: 7295/0
EXHIBIT C-10
Page 1 of 4
DESCRIPTION OF SERVICES & RATES (FY 2022-23)
COMMUNITY CARE ON PALM RIVERSIDE, LLC.
Contractor agrees to provide County with Skilled Nursing Facility/Institutions for Mental Disease
(SNF/IMD) services to adult persons served between the ages of 18 to 64 years with mental health
conditions, pursuant to California's Welfare and Institutions Code, section 5900 et seq., Title 22 of the
California Code of Regulations, the State Department of Health Care Services' Policies and Directives;
and other applicable statutes and regulations that apply to the SNF/IMD facilities and programs.
For the purposes of this Agreement, the term "bed day" includes beds held vacant for persons served
who are temporarily [not more than seven (7) days] absent from a facility. An emergency IMD/SNF
bed-hold for psychiatric and non-psychiatric reasons beyond seven (7) day must be approved by the
County's Department of Behavioral Health (DBH) Director, or designee. The County will pay up to the
first seven (7) bed-hold days and approval must be provided by the County for any additional days after
consulting with the Contractor. The County will have the final say on a case—by-case basis if an
extended bed-hold of beyond seven (7) days is necessary. The Contractor will notify the County
immediately if Contractor has knowledge that the person served will require treatment at a facility or is
eloped lasting seven (7) days or more. A bed hold for non-psychiatric reasons include, but are not
limited to, medical hospitalization or elopement.
In addition to the services listed in "Scope of Work"(Exhibit B), Contractor shall provide the following:
I. BASIC DAILY RATE SERVICES:
Basic Daily Rate services consist of usual and customary SNF services to adult persons served
with medical and mental health conditions.
Basic Daily Rate services include reasonable access to required medical treatment, up-to-date
psychopharmacology, transportation to needed off-site services and bilingual/bicultural
programming.
II. ENHANCED SERVICES:
Enhanced Services consist of specialized program services, which augment basic services.
Enhanced Services are designed to serve persons who have sub-acute psychiatric impairment
and/or whose adaptive functioning is severely impaired.
A charge in addition to the Enhanced Services bed rate may be negotiated for an individual
person served on an as-needed basis between the County's Department of Behavioral Health
(DBH) Director, or designee, and Contractor for Enhanced and STP services by using the
Special Services Authorization Form (Exhibit G). The County's DBH Director, or designee, must
approve these rates before the person served is placed or initiation of any enhanced services
takes place.
III. REQUIREMENTS:
Contractor may provide up to forty-nine (49) beds per day for authorized County persons served
during each term of the Agreement, as needed by the County, subject to availability of said beds
by the Contractor. The County does not guarantee any minimum number of beds for all
services provided by the Contractor and payment will be based on usage.
i
EXHIBIT C-10
Page 2 of 4
IV. RATES*
See"Community Care on Palm Riverside, LLC Rate Table 2022-23"attached.
*All rates other than the Basic Daily Rate services must be pre-approved by the County's DBH
Director, or designee, prior to placement or initiation of such services. For any rate higher than
the Basic Rate Services, both the rationale and the extra services must be specified and time-
limited and approval must be sought using the Special Services Authorization Form (Exhibit G).
** Bed Hold Rate — Person Served out at Hospital. The below rate will be paid up to seven (7)
days without authorization required.
"Psychiatric services (provided to persons served placed by County at Contractor's facilities
who are not covered by Medi-Cal, private insurance or personal/other funds) shall be billed
through the Contractor via the monthly service invoice. Psychiatric services billed by the
service provider on Health Insurance Claim Forms (HICF 1500) or other forms directly to
County will be rerouted to Contractor for inclusion in monthly invoice. Contractor shall attach
supporting documentation verifying services provided on all psychiatric invoices submitted.
Supporting documentation should include, but are not limited to, date and location of service,
service provided, service duration, name of provider.
Ancillary outpatient services (laboratory,x-rays, or other medical services performed offsite to a
person served residing in an IMD/SNF/MHRC) must be billed directly to Medi-Cal, pursuant to
Title 22 of the CCR. County shall be informed and/or approve of any such service(s)to Medi-
Cal ineligible persons served in advance of services being provided, where possible. Ancillary
charges for non-Medi-Cal persons served or non-Medi-Cal billable services may be billed
separately from the monthly service invoice and submitted with supporting documentation to
County.
EXHIBIT C-10
Page 3 of 4
COMMUNITY CARE ON PALM RIVERSIDE, LLC.
Rate Table FY 2022-23
022-2023
Facility Rate - Daily Room Reserve Rate $ 242.34
Bedhold Rate $ 242.34
Room Reserve $ 242.34
Private-Single Room $ 260.00
Semi-Private Room $ 218.40
Augmented Services Rates Effective 7/1/2021
Patch A (per diem rate in addition to daily rate) $ 75.42 per day
Patch B (per diem rate in addition to daily rate) $ 150.84 per day
Patch C (per diem rate in addition to daily rate) $ 193.94 per day
Other Services Rate Range
Physician/Psychiatric Services^ $104.00
Bed Hold Rate - Client out at Hospital
Room Reserve Rate- Holding bed for Client prior to Admission
DHCS Website for SNF Rates AB1629
https://www.dhcs.ca.gov/services/medi-cal/Pages/AB1629/LTCAB1629.aspx
EXHIBIT C-10
Page 4 of 4
REVIEWED AND RECOMMENDED FOR APPROVAL:
By
Susa . Holt, Director
Department of Behavioral Health
CONTRACTOR:
COMMUNITY C PALM RIVERSIDE, LLC.
a
By
J
Print Name:
Pe9r� Q
Title:
Cif the Board, or
President, or any Vice President or
Director f Operations
By �'
Print Name: b e-66 e-�(-�`ti .S
Title:
Secretary(of Corporation), or
any Assistant Secretary, or
Chief Financial Officer, or
any Assistant Treasurer/Facility
Administrator
Mailing Address:
4768 Palm Avenue
Riverside, CA 92501
Phone: (951)686-9001 x 102
Email: ap@ccopalm.com
Contact: Marie Toailoa, Business Dev Director
Fund: 0001/10000
Organization: 56302175
Account/Program: 7295/0
REVISED EXHIBIT C-11
Page 1 of 4
DESCRIPTION OF SERVICES & RATES (FY 2022-23)
CALIFORNIA PSYCHIATRIC TRANSITIONS
Contractor agrees to provide County with Mental Health Rehabilitation Center(MHRC)services for adults
with mental health conditions 18 to 64, pursuant to California's Welfare and Institutions Code, section
5900 of seq., Title 22 of the California Code of Regulations, the California Department of Health Care
Services' Policies and Directives, Title 9, California Code of Regulations, Division 1, Sub-Chapter 3.5,
and other applicable statutes and regulations. Participation in MHRCs is limited to facilities that meet the
licensing and certification requirements of the California Department of Health Services Licensing and
Certification Division.
For the purposes of this Agreement, the term "bed day" includes beds held vacant for persons served
who are temporarily (not more than seven (7) days) absent from a facility. A n e m e r g e n c y M H R C
bed hold for psychiatric and non-psychiatric reasons beyond seven (7) day must
be approved by the County's Department of Behavioral Health (DBH) Director, or designee. The County
will pay up to the first seven (7) bed-hold days and approval must be provided by the County for any
additional days after consulting with the Contractor. The County will have the final say on a case—by-
case basis if an extended bed-hold of beyond seven (7) days is necessary. The Contractor will notify the
County immediately if Contractor has knowledge that the person served will require treatment at a facility
or is eloped lasting seven (7) days or more. A bed hold for non-psychiatric reasons include, but are not
limited to, medical hospitalization or elopement.
In addition to the services listed in "Scope of Work" (Exhibit B), Contractor shall provide the following:
I. BASIC DAILY RATE SERVICES
Basic Daily Rate services consist of usual and customary MHRC services to adults with mental
health conditions. Basic Daily Rate services include reasonable access to required medical
treatment, up-to-date psych opharmacology, transportation to needed off-site services and
bilingual/bicultural programming.
ll. ENHANCED SERVICES
Enhanced Services consist of specialized program services which augment basic services.
Enhanced Services are designed to serve persons who have sub-acute psychiatric impairment
and/or whose adaptive functioning is severely impaired.
The Enhanced Services bed rate or any other charges in addition to the Enhanced Services bed
rate may be negotiated for an individual person served on an as-needed basis between the
County's Department of Behavioral Health (DBH) Director, or designee, and Contractor. The
County's DBH Director, or designee, must approve these rates before the person served is
provided any services more intensive than the Basic Services. Approval for such services may
be sought using the Special Services Authorization Form (Exhibit G).
The need for continuing Enhanced Services will be re-assessed on a weekly to monthly basis
throughout the individual's stay.
III. REQUIREMENTS
Contractor shall provide available beds needed for authorized County persons served during the
term of the Agreement. The County does not guarantee any minimum number of beds.
REVISED EXHIBIT C-11
Page 2 of 4
IV. RATES
See "California Psychiatric Transitions Rate Table 2022-2023" attached. Rates are inclusive of
psychiatric services.
All rates other than the Basic Daily Rate services must be pre-approved by the County's DBH
Director, or designee, prior to placement or initiation of such services. For any rate higher than
the Basic Rate Services, both the rationale and the extra services must be specified and time-
limited and approval must be sought using the Special Services Authorization Form (Exhibit G).
Ancillary outpatient services (laboratory, x-rays, or other medical services performed offsite to a
person served residing in an IMD/SNF/MHRC) must be billed directly to Medi-Cal, pursuant to
Title 22 of the CCR. County shall be informed and/or approve of any such service(s) to Medi-Cal
ineligible persons served in advance of services being provided, where possible. Ancillary
charges for non-Medi-Cal persons served or non-Medi-Cal billable services may be billed
separately from the monthly service invoice and submitted with supporting documentation to
County.
V. CONTRACT PAYMENT SCHEDULE
In its dealings with California Psychiatric Transitions, the County will ensure payment within thirty
(30) days after receipt and verification of Contractor's invoices or communicate to Contractor
when such timeframe cannot be met for any reason.
Contractor agrees to send invoices to:
• DBH-Invoices(a)-fresnoountyca.gov
• dbhinvoicereview(aDfresnocountyca.gov
• dbhcontractedservicesdivision a(�fresnocountVca.gov
VI. ADMISSIONS AGREEMENT
Prior to a person's served admission, County staff shall complete a copy of Contractor's
residential admission packet, to be honored by the admitting County, as applicable for
each person.
REVISED EXHIBIT C-11
Page 3of4
California Psychiatric Transitions Rate Table FY
2022-2023
MHRC
Level 1 $460/Day
1 :1 Monitoring $52.00/Hour
DBU
Level 1 $910/Day
1 :1 Monitoring $52.00/Hour
DIVERSION
Level (IST &/or DIV) $660/Day
1 :1 Monitoring $52.00/Hour
Bed hold rate will be the same rate as the corresponding unit that the bed is being held in.
REVISED EXHIBIT C-11
Page 4 of 4
REVIEWED AND RECOMMENDED FOR APPROVAL:
By
Susan L. irector
Department of Behavioral Health
CONTRACTOR:
California Psychiatric Transitions
By
Print Name: ,d4F-01.J S7_&?
Title: //�ZG��U7z-
Chairman of the Board, or
President, or any Vice President or
Director of Operations
By - ---M- 114
Print Name:Name: Julia Youga
Title: Controller
Secretary (of Corporation), or
any Assistant Secretary, or
Chief Financial Officer, or
any Assistant Treasurer/Facility
Administrator
Mailing Address:
9226 N. Hinton Ave.
Delhi, CA 95315
Phone: (209) 920-920-4799
Fax: (209) 920-4799
Email: astocking@cptmhrc.com
Contact: Aaron Stocking, Director
Fund: 0001/10000
Organization: 56302175
Account/Program: 7295/0
REVISED EXHIBIT C-12
Page 1 of 3
DESCRIPTION OF SERVICES & RATES (FY 2022-23)
GOLDEN STATE HEALTH CENTERS, INC.,
d.b.a.SYLMAR HEALTH AND REHABILITATION CENTER
Contractor agrees to provide County with Skilled Nursing Facility/Institutions for Mental Disease
(SNF/IMD)services to adult persons served between the ages of 18 to 64 years with mental health
conditions, pursuant to California's Welfare and Institutions Code, section 5900 et seq., Title 22 of
the California Code of Regulations, the California Department of Health Care Services' Policies
and Directives; and other applicable statutes and regulations that apply to the SNF/IMD facilities
and programs.
For the purposes of this Agreement, the term "bed day" includes beds held vacant for persons
served who are temporarily [not more than seven (7)days]absent from a facility. An emergency
IMD/SNF bed-hold for psychiatric and non-psychiatric reasons beyond seven (7) day must be
approved by the County's Department of Behavioral Health (DBH) Director, or designee. The
County will pay up to the first seven (7) bed-hold days and approval must be provided by the
County for any additional days after consulting with the Contractor. The County will have the final
say on a case—by-case basis if an extended bed-hold of beyond seven (7)days is necessary.The
Contractor will notify the County immediately if Contractor has knowledge that the person served
will require treatment at a facility or is eloped lasting seven (7)days or more. A bed hold for non-
psychiatric reasons includes, but is not limited to, medical hospitalization or elopement.
In addition to the services listed in "Scope of Work" (Exhibit B), Contractor shall provide the
following:
I. BASIC DAILY RATE SERVICES
Basic Daily Rate services consist of usual and customary SNF/IMD services to adult
persons served with mental health conditions. Basic Daily Rate services include reasonable
access to required medical treatment, up-to-date psychopharmacology,transportation to
needed off-site services and bilingual/bicultural programming.
II. ENHANCED SERVICES
Enhanced Services consist of specialized program services which augment basic services.
Enhanced Services are designed to serve persons who have sub-acute psychiatric
impairment and/or whose adaptive functioning is severely impaired.
Other charges in addition to the Enhanced Services bed rate may be negotiated for an
individual person served on an as-needed basis between the County's Department of
Behavioral Health (DBH) Director, or designee, and Contractor. The County's DBH
Director, or designee, must approve these rates before the person served is placed or
initiation of any enhanced services takes place. Approval for such services may be sought
using the Special Services Authorization Form (Exhibit G).
111. SUB-ACUTE TREAIME TSERVICES
Sub-acute SNF includes services that are non-acute 24-hour voluntary or involuntary care
that is required for the provision of mental health services to adult persons served with a
mental health condition who are not in need of acute mental health care, but who require
general mental health evaluation, diagnostic assessment, treatment, nursing and/or
related services, on a 24-hour per day basis in order to achieve stabilization and/or an
optimal level of functioning.Such persons are those who,if in the community,would require
the services of a licensed health facility providing 24-hour sub-acute mental health care.
Such facilities include,but are not limited to,Skilled Nursing Facilities with special treatment
programs. Sub-acute has the same meaning as non-acute as defined in this section.
REVISED EXHIBIT C-12
Page 2 of 3
IV. REQUIREMENTS
Contractor shall provide available beds needed for authorized County persons served
during the term of the Agreement. The County does not guarantee any minimum
number of beds for all services provided by the Contractor and payment will be based
on usage.
V. RATES*
Program Services Rate
Basic Daily Rate(IMD/STP with Medi-Cal)" $203.69 per person served per day
Bed Hold Rate $195.34 per person served per day
Enhanced Services Rate (with Medi-Cal)** $229.54 per person served per day
Subacute $279.24 per person served per day
Other Services • Rate:Range
Physician/Psychiatric Services " $75/$190 per visit
* All services other than the Basic Daily Rate, and Subacute services, must be pre-
approved by the County's DBH Director,or designee, prior to placement or initiation of
such services. For any services higher than the Basic Daily Rate services,or Subacute
services, both the rationale and the extra services must be specified and time-limited
and approval must be sought using the Special Services Authorization Form (Exhibit
G).
The Basic Daily Rate services, and Subacute services, will either be inclusive of all
physician/psychiatric services provided to persons such as weekly visits, which may
consist of an initial, brief or routine psychiatric assessments/visits, and annual
evaluation and declarations for LIPS conservatorship renewal, or a separate rate (or
rate range)shall be established for psychiatric services as stated below.
'*Rate is set at the State Medi-Cal rate and will be adjusted if the Medi-Cal rate changes.
In the event a person served is placed who does not have Medi-Cal and is under age
65, County will pay both the basic daily rate and the enhanced service rate.
" Physician/psychiatric services (provided to persons served placed by County at
Contractor's facilities) not covered by Medi-Cal, private insurance or personal/other
funds shall be billed through the Contractor via the monthly service invoice. Psychiatric
services billed by the service provider on Health Insurance Claim Forms (HICF 1500)
or other forms directly to County will be rerouted to Contractor for inclusion in monthly
invoice. Contractor shall attach supporting documentation verifying services provided
on all psychiatric invoices submitted. Supporting documentation should include, but is
not limited to, date and location of service, service provided, service duration, name of
provider.
Ancillary outpatient services (laboratory, x-rays, or other medical services performed
offsite to a person served residing in an IMD/SNF/MHRC) must be billed directly to
Medi-Cal, pursuant to Title 22 of the CCR. County shall be informed and/or approve of
any such service(s)to Medi-Cal ineligible persons served in advance of services being
provided, where possible. Ancillary charges for non-Medi-Cal persons served or non-
Medi-Cal billable services may be billed separately from the monthly service invoice
and submitted with supporting documentation to County.
REVISED EXHIBIT C-12
Page 3 of 3
REVIEWED AND RECOMMENDED FOR APPROVAL:
By
Susan L Holt, Director
Department of Behavioral Health
CONTRACTOR
GOLDEN STATE HEALTH CENTERS, INC.,
d.b.a. SYLMAR HEALTH AND REHABILITATION CENTER
Bys"` --
101/
Print Name:
Title: Pcyi�fi�j"„1/ ��' !)
Chairman of the Board, or
President, or any Vice President or
Director of Operations
By
Print Name: �"'�CKgZ Gent a-ty s
Title: C,%p Vorrt c ecreA,�r�
Secretary(of Corporation), or
any Assistant Secretary, or
Chief Financial Officer, or
any Assistant Treasurer/Facility
Administrator
Mailing Address:
12220 Foothill Blvd.
Sylmar, Ca 91342
Phone: (818) 834-5082
Fax: (818)896-8097
Email: mrmweiss@gmail.com
Contact: Martin Weiss, President
Fund: 0001/10000
Organization: 56302175
Account/Program: 7295/0
EXHIBIT C-13
Page 1 of 3
DESCRIPTION OF SERVICES & RATES (FY 2022-23)
COUNTRYSIDE CARE CENTER, LLC
Contractor agrees to provide County with Skilled Nursing Facility (SNF)/Institutions for Mental Disease
(IMD) services for mentally disabled adult persons ages 18 or older, pursuant to California's
Welfare and Institutions Code, Division 5, commencing with section 5000, Title 22 of the California
Code of Regulations, sections 72001, et seq.; the California Department of Health Care Services'
Policies and Directives, and other applicable statutes and regulations.
For the purposes of this Agreement, the term "bed day" includes beds held vacant for persons
served who are temporarily [not more than seven (7) days] absent from a facility. An emergency
IMD/SNF bed-hold for psychiatric and non-psychiatric reasons beyond seven (7) day must be
approved by the County's Department of Behavioral Health (DBH) Director, or designee. The County
will pay up to the first seven (7) bed-hold days and approval must be provided by the County for any
additional days after consulting with the Contractor. The County will have the final say on a
case—by-case basis if an extended bed-hold of beyond seven (7) days is necessary. The
Contractor will notify the County immediately if Contractor has knowledge that the person served
will require treatment at a facility or is eloped lasting seven (7) days or more. A bed hold for non-
psychiatric include, but are not limited to, medical hospitalization or elopement.
In addition to the services listed in "Scope of Work" (Exhibit B), Contractor shall provide the following
I. BASIC DAILY RATE SERVICES
Basic Daily Rate services consist of usual and customary SNF/IMD services to adults with
mental health conditions, plus those services that are included in Special Treatment Programs
as contained in Title 22 of the California Code of Regulations, sections 72443-72475.
Basic Daily Rate services include reasonable access to required medical treatment, up-to-date
psychopharmacology, transportation to needed off-site services and bilingual/bicultural
programming.
SPECIAL TREATMENT PROGRAMS
Special Treatment Programs (STP) serve persons served who have a chronic psychiatric
impairment and whose adaptive functioning is moderately impaired. These persons served
require continuous supervision and may be expected to benefit from an active rehabilitation
program designed to improve their adaptive functioning or prevent any further deterioration of
their adaptive functioning. Services are provided to individuals having special needs or deficits
in one (1) or more of the following areas: self-help skills; behavioral adjustment; interpersonal
relationships; pre-vocation preparation, alternative placement planning, and/or pre-release
planning.
II. ENHANCED SERVICES
Enhanced Services consist of specialized program services which augment basic services.
Enhanced Services are designed to serve persons served who have sub-acute psychiatric
impairment and/or whose adaptive functioning is severely impaired.
EXHIBIT C-13
Page 2 of 3
A charge in addition to the Enhanced Services bed rate may be negotiated on an individual
person served need basis between County's DBH Director, or designee, and Contractor for
Enhanced and STP services by using the Special Services Authorization Form (Exhibit G). The
County's DBH Director, or designee, must approve these rates before the person served is
placed or initiation of any enhanced services takes place.
III. REQUIREMENTS
Contractor shall provide up to thirty-five (35) beds per day for authorized County persons served
during each term of the Agreement. In addition, Contractor shall provide additional beds as
needed by the County, subject to availability of said beds by the Contractor. The County does
not guarantee any minimum number of beds for all services provided by the Contractor and
payment will be based on usage.
IV. RATES*
See "Countryside Care Center LLC Rate Table 2022-2023" attached.
*All rates other than the Basic Daily Rate must be pre-approved by the County's DBH Director,
or designee, prior to placement or initiation of such services. For any rate higher than the
Basic Rate Services, both the rationale and the extra services must be specified and time-
limited and approval must be sought using the Special Services Authorization Form (Exhibit G)
or a form agreed upon by COUNTY and CONTRACTOR.
^Psychiatric services (provided to persons served placed by County at Contractor's facilities
who are not covered by Medi-Cal, private insurance or personal/other funds) shall be billed
through the Contractor via the monthly service invoice. Psychiatric services billed by the
service provider on Health Insurance Claim Forms (HICF 1500) or other forms directly to
County will be rerouted to Contractor for inclusion in monthly invoice. Contractor shall attach
supporting documentation verifying services provided on all psychiatric invoices submitted.
Supporting documentation should include, but are not limited to, date and location of service,
service provided, service duration, name of provider.
Ancillary outpatient services (laboratory, x-rays, or other medical services performed offsite to a
person served residing in an IMD/SNF/MHRC) must be billed directly to Medi-Cal, pursuant to
Title 22 of the CCR. County shall be informed and/or approve of any such service(s) to Medi-
Cal ineligible persons served in advance of services being provided, where possible. Ancillary
charges for non-Medi-Cal persons served or non-Medi-Cal billable services may be billed
separately from the monthly service invoice and submitted with supporting documentation to
County.
EXHIBIT C-13
Page 3 of 3
COUNTRYSIDE CARE CENTER, LLC
Rate Table FY 22-23
Institution of Mental Disease Rates
Service Levels FY 2022-2023
Basic Daily Rate (IMD/STP with Medi-Cal) $275.00 per person per day
Basic Daily Rate (IMD/STP without Medi-Cal) $275.00 per person per day
Basic Daily Rate - Bed Hold** $266.07 per person per day
Level 1 Patch $80.00 per person per day
Level 2 Patch $150.00 per person per day
Level 3 Patch $200.00 per person per day
High Specialty Population Case by Case Negotiation
**Bed Hold Rate — Person Served out at Hospital. Above rate will be paid up to seven (7) days without
authorization required.
By By �j
Print Name: Jacob Unger Print Name: Jacob Unger
Title: President Title: Chief Financial Officer
Chairperson of the Board, or Secretary(of Corporation), or
President, or any Vice President any Assistant Secretary, or
Chief Financial Officer, or
any Assistant Treasurer
Mailing Address:
5404 Whitsett Ave, Ste 182
Valley VLG, CA 91607
Phone: (510) 386-7151
Email: Manny.Galit@countrysidecarecenter.com
Contact: Manny Galit
Agreement 21-258 Contact List
Avenue
Contact Natalie D'Attile
Email NDattile@frontst.com
Address 2115 7th Ave Santa Cruz, CA 95062
Phone (831)420-0120(x109)
California Psychiatric Transitions
Contact Aaron Stocking
Email astocking@cptmhrc.com
Address 9226 N Hinton Ave Delhi, CA 95315
Phone (209)667-9304
Mental Health Management 1,Inc., . .
.a. Canyon Manor
Contact Paul Heil
Email Paul.Heil@canyonmanor.corr
Address 655 Canyon Manor Rd Novato, CA 94947
Phone (415)892-1628(x306)
CIF Merced Behavioral, LLC.,cl.b.a. CIF Merced Behavioral Center
Contact Jeri Allgood
Email Jeri.Allgood@mercedbehavioral.com
Address 1255"B"St Merced,CA 95341
Phone (209)723-8814
Crestwood Behavioral . cl.b.a. Idy1wood Care Center
Contact Elena Mashkevich
Email elena.mashkevich@cbhi.net
Address 520 Capitol Mall,Suite 800 Sacramento, CA 95814
Phone (916) 764-5310
KF Community Care Center,LLC.,cl.b.a.Community Care Center
Contact Shannon Bland
Email Shannon.Bland@huntingtondrivehcc.com
Address 2335 S Mountain Ave Duarte, CA 91010
Phone (626)445-2421(x200)
Agreement 21-258 Contact List
Medical Hill Rehabilitation Center,ILLC.,d.b.a.Kindred Nursing and Rehabilitation—Medical Hill
Contact Andrew Snider
Email andrew.snider@mcclurepa.com
Address 475 29th St Oakland,CA 94609
Phone (661)886-9249
Community Care on Palm Riverside,LILC
Contact Shahrzad Jannat
Email administrator@foothillops.com
Address 4768 Palm Ave Riverside,CA 92501
Phone (626)798-1111
CorporationTelecare
Contact Daniel Beckerman
Email dbeckerman@telecarecorp.com
Address 1087 Marina Village Parkway, Suite 100 Alameda,CA 94062
Phone (510)337-7950(x1517)
Cordilleras Mental Health Center; Garfield Neurobehavioral;Gladman;Golden
Divisions: Living Center San Jose; La Paz; Morton Bakar;Villa Fairmont
Golden State Health Centers,Inc.,cl.b.a.Sylmar Health and Rehabilitation Center
Contact Martin Weiss
Email mrmweiss@gmail.com
Address 12220 Foothill Blvd Sylmar,CA 91342
Phone (818)384-5082
Vista Pacifica Enterprises,Inc.,cl.b.a.Vista Pacifica Center(and Vista Pacifica Convalescent)
Contact Cheryl Jumonville
Email ciumonville@vistapacificaent.com
Center: 3674 Pacific Ave Riverside,CA 92509
Address Convalescent:3675 Pacific Ave, Riverside, CA 92509
Phone (916)682-4833(x106)
Countryside Care Center,LLC
Contact Manny Galit
Email Manny.galit@countrysidecarecenter.com
Address 5404 Whitsett Ave STE 182 Valley Village, CA 91607
Phone (510)386-7151